https://orcid.org/0000-0002-2387-6297 
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Leprosy still affects many lives in Nepal. Despite achieving elimination of leprosy as a public health problem at national level in 2009, more than 3000 new cases of leprosy were reported annually afterwards.1,2 Around 80% of these new cases are reported by 17 Terai districts in the South indicating that transmission and incidence of leprosy have not been interrupted yet and that intensive efforts to control and manage leprosy in the Terai districts should be continued.3,4
Although annual active case finding campaigns are part of leprosy control in Nepal, the majority of the patients present voluntarily, in some cases with severe and permanent impairments due to detection delay. Detection delay can be caused by lack of ability of individuals to recognize the nature of the symptoms, fear of community isolation should one be diagnosed with leprosy or a health professional’s failure to diagnose the disease.5
Since 2000, the proportion of Grade 2 disability (G2D) among new cases has decreased from 8% 6 to 4.7% in 2019.4 Disability at the time of diagnosis is often used as an indicator of severity of impairment and as a proxy indicator for delayed diagnosis.7,8 Disability due to leprosy can be measured using the WHO disability grading and/or the eye-hand-foot (EHF) score. In the WHO disability grading, no impairment in eye, hand or foot is graded as 0, presence of eye (visual acuity >6/60 in either eye) or sensory impairment in hand or foot but no visible deformity or damage is graded as 1, and severe visual impairment (visual acuity <6/60 or inability to count fingers at 6 m) or visible deformity or damage in hand or foot is graded as 2.9 The EHF score is a sum score of the WHO impairment grades of both eyes, hands and feet (range from 0 to 12) and is often used as an indicator of the severity of impairment.8 Repeat grading at the end of MDT therapy can be used as an indicator of the effect of treatment on disability (i.e., improvement or deterioration).8,10
Recently, Geographic Information Systems (GIS) techniques have been used to identify areas of high incidence or prevalence of leprosy, child (below the age of 15) and G2D cases. These cumulative incidence maps are often used to target early case detection campaigns and preventive treatment interventions.11 They indicate (i) areas that used to be or are currently highly endemic for leprosy, requiring intensified preventive treatment and active case detection, (ii) areas where a high number of new cases with G2D were detected in recent years indicating delay in case detection, (iii) and areas with a high cumulative number of people with leprosy-related disabilities where disability services are needed. The cumulative G2D maps can also be used to indicate areas where the delay in case detection is likely to be longer so that possible underlying causes can be investigated, such as poor ability of health professionals to detect leprosy, lack of awareness in the community or limited leprosy services.12 These maps can support leprosy programme managers and policymakers in developing their leprosy elimination strategies in the long term. The more specifically they can identify these areas, the better the programme manager can target these areas and deploy resources and leprosy services. Therefore, it is important to investigate at what level these clusters of people (new cases and cases with G2D) can be detected. Cumulative incidence and G2D maps that present the leprosy situation over a period of time and at municipality and ward level have not been developed for Nepal yet. Therefore, this study aims to describe the geographical distribution of leprosy case detection and G2D at district, municipality and ward level and the EHF trend in cases with disabilities from 2010 to 2021 in two leprosy-endemic provinces in Nepal.
Methods
This study describes the spatial distribution of newly detected leprosy patients that are registered at health centres (i.e., hospitals, health posts, and primary health care centres) in Province 1 and Province 7, Nepal, between July 2010 and July 2021. Province 1 is the easternmost of the seven provinces of Nepal and has an area of 25,905 km2 and a population of almost 5 million in 2021. It consists of 14 districts which are further divided into 49 urban municipalities, including one metropolitan city and two sub-metropolitan cities, and 88 rural municipalities (Figure S1 in Supplementary File).13 Province 7, also known as Sudurpaschim Province, is the most Western province of Nepal and has an area of 19,515 km2 and population of around 2.7 million in 2021. It consists of 9 districts divided into 34 urban municipalities, including one sub-metropolitan city, and 54 rural municipalities (Figure S1 in Supplementary File).14 Both Provinces can be divided into three major ecological regions, (i) the Terai in the south, which is a lowland region that shares the border with India, covers 20% of the total area and holds almost 50% of the population, (ii) the middle Hills region consisting of the Mahabharat range and the Churia Hills that cover around 65% of the total area and is home to 45% of the population, and (iii) the Himalaya to the north which is a snowy mountainous region that accounts for 15% of the total area and is the least inhabited region, accounting for only 7% of the population. Both Provinces 1 and 7 are considered highly endemic for leprosy with a new case detection rate (NCDR) of 96.6 per 1,000,000 population in Province 1 and 92.8 per 1,000,000 population in Province 7 in 2018–19.4
Data collection
The data collection was part of a COR-NTD-supported project coordinated by NLR Nepal. We requested the patient information on all available medical records of new leprosy patients registered from 2010 to 2021 from the Primary Health Centres (PHCs) and Health Posts in Province 1 and Province 7. The patient information included name, address, gender, age, date of diagnosis, type of leprosy, type of disability at time of diagnosis and EHF score at time of diagnosis. Local GIS research assistants, health workers and female community health volunteers travelled to the residences of the former patients. They explained the study and asked for verbal consent to collect GPS coordinates of their residence (longitude and latitude) using the Data Health Information System 2 (DHIS2) application version 2.33 (Health Information Systems Programme Developer team, Oslo (2019)), a mobile application for health-related data collection and management. At the same time, patient information was updated and completed in the DHIS2 tool. All data were uploaded daily to a server in Kathmandu. Serial numbers were randomly assigned to each data point to anonymize the data. All anonymized data points were processed and verified using the open-source Quantum Geographic Information System (QGIS) version 3.4.1 (QGIS Developer team, Madeira (2018)). Shapefiles at district, municipality and ward level of Provinces 1 and 7 from 2020 were obtained from the ‘Humanitarian Data Exchange’ website (https://data.humdata.org/).
Spatial analysis
We visualized the spatial distribution of new cases detected (NCD) and new cases with G2D in Provinces 1 and 7 in QGIS. The spatial data were combined with the patient information from the medical records. The NCD and the number of new cases with G2D were calculated per district, municipality and ward in both provinces using the ‘count points in polygons’ tool in QGIS. Detailed maps were created of both provinces to compare the distribution of NCD and G2D cases for two time periods: (1) 2010 to 2015 and (2) 2016 to 2021.
EHF score
We presented the EHF scores at time of diagnosis of all cases with Grade 1 disability (G1D) and G2D (i.e., EHF score ≥1) per year for both provinces. Although the EHF scores do not show a normal distribution, we chose to compute the mean EHF score per year and the 95% confidence intervals. Moreover, we calculated the proportion of cases with low, moderate and high severity of disability per year as follows: the number of cases with EHF scores between 1 and 4 divided by the total number of cases with EHF scores ≥1 as ‘low’, the number of cases with EHF scores between 5 and 7 divided by the total number of cases with EHF scores ≥1 as ‘moderate’, and the number of cases with EHF scores between 8 and 12 divided by the total number of cases with EHF scores ≥1 as ‘high’. Officially the EHF score measures the level of severity of impairments, however, in this study we call it severity of disability.
Results
From 2010 to 2021, 6555 new leprosy cases were registered at health facilities in Province 1 and 2535 in Province 7. We collected spatial data for 6034 (92%) and 2492 (98%) individuals, respectively (Table 1). In Province 1, 3358 new cases were registered between 2010 and 2015 and 2676 cases between 2016 and 2021. The corresponding figures were 1164 and 1328 in Province 7.
Table 1
Study sample and demographics of the mapped new leprosy patients registered for treatment in Provinces 1 and 7 of Nepal between 2010 and 2021.
| Province 1 | Province 7 | ||||
|---|---|---|---|---|---|
| 2010–2015 | 2016–2021 | 2010–2015 | 2016–2021 | ||
| Cases mapped | 3358 | 2676 | 1164 | 1328 | |
| Mean age | Female Male | 35.036.8 | 37.738.2 | 40.240.8 | 41.043.1 |
| Child cases age <15 (%) | 291 (9%) | 189 (7%)* | 33 (3%) | 57 (4%) | |
| Female cases (%) | 1403 (42%) | 1187 (44%) | 496 (43%) | 574 (43%) | |
| MB leprosy cases (%) | 1809 (54%) | 1674 (63%)* | 694 (60%) | 972 (73%)* | |
| G2D cases (%) | TotalAdultChild | 225 (7%)217 (7%)8 (3%) | 144 (5%)*138 (6%)6 (3%) | 79 (7%)79 (7%)0 (-) | 136 (10%)*133 (10%)3 (5%) |
| G1D cases (%) | TotalAdultChild | 315 (9%)289 (9%)26 (9%) | 98 (4%)*97 (4%)1 (1%) | 55 (5%)53 (5%)2 (6%) | 94 (7%)*94 (7%)0 (-) |
| Mean EHF score (95% CI) | OverallAdultChild | 1.7 (1.63–1.79)1.71.3 | 2.1* (1.93–2.25)2.11.9 | 3.6 (3.18–4.02)3.61.0 | 3.8 (3.49–4.13)3.83.0 |
*p < 0.05 (compare proportions between time periods with Z-test in EpiCalc 2000 version 1.02).
Study sample
Table 1 presents demographic and epidemiologic characteristics of the study sample for Provinces 1 and 7 in two time periods. In Province 1, the proportion of child cases below 15 years, G1D and G2D decreased significantly between the first and second period. While the proportion of G1D and G2D increased significantly in Province 7.
Figure 1 shows the trends of NCD, the proportion of G1D and G2D, and the proportion of child cases below 15 years old among new cases at national level, in Province 1 and in Province 7. The national leprosy trend was stable with a peak in 2019 followed by a steep decrease in 2020 (Figure 1A). The national G2D trend increased from 3% to almost 6% from 2010 to 2020 (Figure 1B) and the child trend fluctuated between 4% and 8% (Figure 1C). Province 1 shows decreasing leprosy, G1D and child trends from 2010 to 2021 (Figure 1D, 1E and 1F) and an increase in the G2D trend from 2017 to 2020 (Figure 1E). Province 7 shows a stable leprosy trend with an increase in new cases in 2018 (Figure 1G). The G1D and G2D trends show an increase from 2010 to 2021 (Figure 1H), while the child trend fluctuates between 1% and 6% (Figure 1D).
Figure 1.
Leprosy, disability and child case (<15 years) trends at national level from 2010 to 2020 (the year 2021 is not available) and for Provinces 1 and 7 from 2010 to 2021. Leprosy trends (A, D and G): the grey line is the number of new cases (NCD) reported and the stars indicate the events that may have affected the leprosy trend, including (i) LPEP activities in Province 1 first and later SDR-PEP roll out in more districts including in Province 7 (2014 to 2018)15, (ii) door-to-door campaigns in 2019 and (iii) onset of the COVID-19 pandemic in mid-2020. Disability trends (B, E and H): the solid blue line is the proportion of Grade 2 disability (G2D) among the new cases detected at national level and for Provinces 1 and 7, and the blue dotted line is the proportion of Grade 1 disability (G1D) for Provinces 1 and 7. The child case trends (C, F and I): the orange line is the proportion of child cases among the new case detected at national level and for Provinces 1 and 7.
Geographical distribution of the NCD and G2D cases in Province 1
From 2010 to 2015, the majority of the new cases were identified in the Terai region of the province (Figure 2). Three districts (Jhapa, Morang and Sunsari) had more than 500 new cases each cumulatively (Figure 2A). Within these districts, five municipalities in Morang and one in Sunsari had an NCD between 100 and 499 (Figure 2C). Zooming in, geographic variations become visible. We identified one urban ward (Itahari N.P.) in Sunsari that had 100 new cases and one urban ward (Biratnagar N.P.) in Morang that had 383 new cases (Figure 2E). These two wards are surrounded by wards with less than 25 new cases. In the Hill and Mountainous districts of the province, we identified 43 municipalities and 434 wards with zero leprosy cases (Figure 2C and 2E).
Figure 2.
The geographical distribution of the cumulative leprosy new case detection (NCD) at district and municipality, and for Sunsari, Morang and Jhapa district at ward level from 2010 to 2015 and 2016 to 2021 in Province 1.
From 2016 to 2021, the majority of the cases were again registered in the Terai region (Figure 2B, D and F). Two municipalities (Biratnagar and Sunwarshi) and one ward (Biratnagar N.P.) in Morang district remained with an NCD between 100 and 499 (313, 144 and 294, respectively). In Jhapa district, we identified two municipalities (Bhadrapur and Kachankawal) and 38 wards that had a higher number of cumulative new cases compared to the first period. More municipalities (52) and wards (450) had zero leprosy cases compared to the first period (Figure 2D and F).
Among the cumulative number of new leprosy cases registered in Province 1, 225 cases (7%) were detected with G2D from 2010 to 2015 and 144 cases (5%) from 2016 to 2021. In the period 2010 to 2015, we identified two districts (Sunsari and Morang) with a cumulative number of more than 50 G2D cases (Figure 3A). In Morang, one ward (Biratnagar N.P.) had 29 cases and accounted for all cases in Biratnagar municipality (Figure 3E). The 90 municipalities with zero G2D cases are located in the Hills and Mountainous region of the province (Figure 3C and E).
Figure 3.
The geographical distribution of the cumulative new cases with Grade 2 disability (G2D) at district and municipality, and for Sunsari, Morang and Jhapa district at ward level from 2010 to 2015 and 2016 to 2021 in Province 1.
From 2016 to 2021, the number of districts with zero leprosy cases with G2D increased to 8 and the number of G2D cases in Biratnagar N.P. decreased to 16 (Figure 3B and F). In the Mountainous and Hills regions of the province, more municipalities and wards with zero G2D cases were identified, in total 98 and 613 respectively (Figure 3D and F).
Geographical distribution of the NCD and G2D cases in Province 7
From 2010 to 2015, similar to Province 1, the majority of the cases were identified in the Terai region of the province (Figure 4). One urban ward (Dhangadhi N.P.) located in Dhangadhi municipality in Kailali district had 183 new cases of leprosy (Figure 4E). Forty-two municipalities had a cumulative 6-year NCD of less than 25, while 36 municipalities and 259 wards with zero leprosy cases were located in the Hill and Mountainous region of the province (Figure 4C and E).
Figure 4.
The geographical distribution of the cumulative leprosy new case detection (NCD) at district and municipality, and at ward level for Terai and Hills districts from 2010 to 2015 and 2016 to 2021 in Province 7.
From 2016 to 2021, the majority of the new cases were detected in the Terai region of the province while an increase in NCD was identified in the municipalities of Achham, Doti and Baitadi districts in the Hills region (Figure 4B). The number of municipalities and wards with zero leprosy cases, mainly located in the North, decreased to 15 and 200, respectively (Figure 4D and F).
Among the cumulative total of leprosy cases detected in Province 7, 79 cases (7%) were detected with G2D from 2010 to 2015 and 136 cases (10%) from 2016 to 2021. From 2010 to 2015, Kailali district had 29 cases of G2D and Achham district had 19 cases (Figure 5A). Throughout the province, we identified 3 municipalities and one ward (Dhangadhi N.P.) with 5 to 9 G2D cases in the Terai, whereas 54 municipalities had zero G2D cases (Figure 5C and E). In the period of 2016 to 2021, the number of G2D cases increased from 47 in Kailali district and to 36 in Achham (p > 0.05) (Figure 5B). In Achham district, one municipality increased from 2 G2D cases in 2010–2015 to 10 cases in 2016–2021 (Figure 5C and D). Also, fewer wards (304) mainly located in the Hill and Mountainous region of the province had zero cases in 6 years compared to the 338 wards with zero G2D cases in 2010–2015 (Figure 5E and F).
Figure 5.
The geographical distribution of the cumulative new cases with Grade 2 disability (G2D) at district and municipality, and at ward level for the Terai and Hill districts from 2010 to 2015 and 2016 to 2021 in Province 7.
EHF trend
In Province 1, 2818 and 2423 cases had an EHF-score of zero in 2010–2015 and 2016–2021, respectively. The corresponding figures were 1030 and 1098 in Province 7. For the cases with an EHF-score ≥1, the mean EHF score per year with the 95% confidence intervals and the proportion of cases with low, moderate and high severity of disability were calculated for both provinces (Figures 6A to D). In Province 1, the mean EHF score stabilized at 1.7 from 2010 to 2017 and increased significantly to 2.7 in 2020 (p = 0.002) (Figure 6A). This is also seen in the increase in proportions of cases with moderate and high severity of disability from 2018 onwards (Figure 6B). In Province 7, the mean EHF score fluctuated between 2.3 and 4.5 from 2010 to 2021 (Figure 6C). The proportion of low, moderate and high scores also fluctuated, with a peak of 17% of the cases with disability with high severity of disability in 2015 (Figure 6D).
Figure 6.
The mean EHF score per year (coloured line) with 95% confidence intervals (grey lines) for Province 1 (A) and Province 7 (C) and the proportion of cases with low, moderate and high severity of disability per year for Province 1 (B) and Province 7 (D). Yellow indicates low severity (EHF score 1–4), orange moderate severity (EHF score 5–7) and red high severity (EHF score 8–12). *No EHF scores are available in 2021 in Province 1 (A and B).
Discussion
This study compared the cumulative geographical leprosy NCD and G2D distribution in the period 2010 to 2015 with that from 2016 to 2021 in two provinces in Nepal. In Province 1 in the period 2016–2021, we identified a continuous decrease in NCD and proportion of G1D and a lower G2D proportion compared to 2010–2015. While in Province 7, we identified a (continuous) increase in NCD and G1D and a fluctuating G2D. This was also reflected in the mean EHF-score of ≥1, which increased significantly in Province 1 in the second time period and fluctuated in Province 7 in both time periods, with higher percentages of moderate and high severity of disability seen in Province 7. For both provinces, zooming in to ward level showed that some wards (Biratnagar N.P. in Morang and Dhangadhi N.P. in Kailali district) are highly endemic and account for most of the new cases in that district, while those wards may be surrounded by wards with only a few cases (‘sporadic cases’).
The geographic distribution of NCD and G2D in Province 1
We observed that the NCD, the proportion of G1D and the proportion of child cases decreased over time, while the proportion of G2D increased from 2017 onwards. The decrease in NCD and child cases is an indication of reduced transmission of M. leprae in the province. Especially in the Hill and Mountainous region where only 8 child cases below 15 years were reported from 2010 to 2021 (data not shown). Two Terai districts, however, continued to report more than 500 cases, of which 7% were child cases in 2016–2021 (data not shown). In addition, one municipality in Jhapa reported more child cases compared to 2010–2015 (data not shown) indicating that the transmission of M. leprae has not been reduced in this municipality. Despite the lower number of cases with G2D in the second period, the increase in the proportion of G2D since 2017 is an indication of increased case detection delay. This could be the result of lack of involvement by health staff and awareness in community (passive case detection) but needs to be further investigated.12
At ward level, we observed large differences in the cumulative number of new cases and G2D cases between wards in highly endemic districts. For example, Biratnagar N.P. in Morang district is surrounded by wards with few leprosy cases and G2D cases. We also observed a shift in the geographical distribution of leprosy cases from the municipalities and wards in the centre of Terai towards the eastern Terai (Jhapa district) of the province. These observations can be explained by the increase in leprosy control activities that have taken place from 2010 to 2021 in the Terai region in Province 1 (Jhapa and Morang). The National Leprosy Elimination Programme (NLEP) continued with annual case detection campaigns, contact examination and skin camps to detect cases early and find the so-called ‘hidden’ cases. International NGOs also contributed to early case detection, especially through the LPEP Programme that was implemented in the same two districts. In the LPEP programme, the contacts of leprosy patients registered from 2014 to 2018 were examined for leprosy signs and symptoms and, if they did not have any, received a single dose of rifampicin as preventive treatment.16 Although most of the cases are still reporting voluntarily (passive case detection), the active case finding resulted in an increase of new cases in these two districts from 2014 to 2016 followed by a declining trend until 2019 and a decrease in the number of G2D cases (early detection).15 Whether the low number of new cases and the drop in the proportion of G2D and child cases in 2020 are an effect of these active case finding activities or due to the COVID-19 pandemic that started in March 2020 remains unknown.
The geographic distribution of NCD and G2D in Province 7
The NCD, proportion of G2D and proportion of child cases increased over time indicating ongoing transmission of M. leprae. In addition, the number of municipalities and wards that reported new leprosy cases and cases with G2D increased considerably in 2016–2021. Especially the municipalities in the Hills and Terai region (Achham, Doti and Kailali district) show higher cumulative number of new cases and G2D cases. However, geographical variations are visible in Achham and Doti district with some wards reporting zero new cases and G2D cases. The increase in NCD and change in geographical leprosy distribution may be explained by two events that occurred from 2010 to 2021. The boost in the active case finding activities by NLEP in the highly endemic districts and roll-out of SDR-PEP in the eastern Terai district of Province 7 (Kailali district), added to the increase in new cases in the Terai municipalities in the second period. NLEP also organized extensive training in leprosy diagnosis and management for health centre staff in Achham district (Eastern Hills of Province 7) resulting in an increase in the number of new cases and G2D cases from 2014 onwards in the East part of the province. Besides these events, the presence of stigma in the communities may also affect the NCD and G2D numbers. For example, leprosy patients resident in the Hills districts (e.g. Doti) still hesitate to disclose their disease to health staff for fear of discrimination and exclusion.17 As a result, they are detected late.
EHF scores in cases with disability
In this study, we found a higher mean EHF score in cases with disability at diagnosis and higher proportions of moderate and high severity of disability in Province 7 than in Province 1 (see Figure 6B and D). While in Province 1 the cumulative number of new cases with G2D decreased in the period 2016–2021 compared to the 2010–2015, the mean EHF score increased significantly from 1.7 in 2017 to 2.7 in 2020 and the proportion of moderate and high disability severity also increased. A decrease in the number of cases with a disability did not result in a decrease in severity (EHF score). The increase in EHF score can be a result of ‘hidden’ cases that were missed during earlier active case finding campaigns, limited access to leprosy services during the COVID-19 pandemic in mid-2020, or a chance effect due to the small number of cases with disabilities in the second time period. During the time when COVID-19 measures were in force, new cases with milder forms of leprosy may not have been detected, while those with severe forms of leprosy were. In Province 7, where the number of cases with disabilities doubled in the second time period, both the mean EHF score and the proportions of high severity of disability fluctuated between 2010 to 2021. This may have been the effect of the small number of cases with disability and the training of health staff in leprosy diagnosis and management.
Incidence and G2D maps at district, municipality and ward level can be used by programme managers to identify areas that should be targeted with active case finding activities, preventive interventions, or disability services. Considerations in the selection of target areas can be the availability of resources, costs (efficient use of resources), presence of stigma or recent active case finding campaigns. In municipalities where only some wards report new cases or G2D cases, programme managers are advised to target only those wards. Whereas in municipalities where all wards report new cases and G2D cases, targeting the complete municipality or even the complete district can be considered.
In this study, the district, municipality and ward incidence maps of Province 1 showed that, despite the many active case finding campaigns in the past decades, some districts, municipalities and wards in the Terai region continue to be highly endemic for leprosy, and therefore should be target areas for intensified active case finding and preventive treatment. To use scarce resources more efficiently, programme managers are advised to target only those wards that reported higher number of new cases in the second period, for example, wards with more than 25 cases (5 cases per year). The municipalities that show an increase in new cases with G2D (Jhapa) or continuation of new cases with G2D (Morang) should be investigated for detection delay and need of disability services. Considering that many new cases of leprosy are still reporting voluntarily (passive case detection), dissemination of leprosy health education materials to increase awareness of leprosy should be continued or increased, as it is key for early detection. In addition, investigations into the causes of and risk factors for continuous detection delay in these municipalities can improve the active case finding activities.
The district, municipality and ward incidence maps of Province 7 showed an increase in municipalities and wards with new cases of leprosy (Achham, Doti and Baitadi) and an increase in the number of new cases in the municipalities that already reported new cases in the first time period (Kailali and Kanchanpur). Especially in one municipality in Achham (Panchadewal Binayak) the number of child cases increased considerably from zero to 4 (13%) in the second period (data not shown) indicating recent transmission. These municipalities, located in the Hills and Terai region of the province, should be considered for intensified active case finding and preventive treatment to interrupt the transmission of M. leprae. Leprosy health education and awareness raising campaigns should be implemented at the same time to increase the knowledge on leprosy and promote self-referral.5 The G2D maps showed that an increased number of municipalities and wards in the Hills and Terai region of the province reported new cases with G2D. These municipalities most likely require disability services and should be closely investigated for detection delay. As for Province 1, investigations are needed to explore the causes and risk factors for detection delay in Province 7. It is recommended to visualise progress towards interruption of transmission and elimination of leprosy disease in municipalities of both provinces, especially in the Mountainous and Hills region, by using the new phases of elimination of the WHO.18 Potentially important lessons can be learned from this regarding the dynamics of infection and case incidence on the road towards zero leprosy.
Conclusion
This study shows that the leprosy problem is still current in Nepal. The maps presented in this paper show that clustering of both new cases and cases with leprosy-related disability often occurs at ward level. Leprosy policymakers and programme managers can use such maps to develop long-term strategies at district, municipality or ward level using the level that results in most efficient use of resources. This includes specifically targeting the Terai municipalities or wards that continue to be highly endemic for leprosy with intensified active case finding and preventive treatment, investigating case detection delay in those with a high number of new cases with G2D, and providing the Hills and Terai municipalities that show a high cumulative number of G2D cases with disability services.
Supplementary file
Figure S1. Districts of Province 1 and Province 7 (available online at https://doi.org/10.47276/lr.93.4.348).
Review board approval
This study was a part of the COR-NTD project. The COR-NTD research protocol was approved by the ethical review board at the National Health Research Council of the Ministry of Health in Nepal (#412/2020 P).
Acknowledgements
We would like to thank the GIS researchers, health workers and Female Community Health Volunteers of Provinces 1 and 7 for collecting the GPS coordinates of the patient’s houses and patient’ information. We are also grateful to Paul Saunderson, Melissa Edmiston and Leslie Zolman for designing and coordinating the successful COR-NTD project, and for supporting the Nepal team. Lastly, we would like to express our gratitude to the participants in the focus group meeting and dissemination meeting for providing their invaluable input in the COR-NTD project in Nepal.
A conflict of interest (COI) statement
The authors report no conflict of interest.
Funding
Funding for this study was provided through the COR-NTD project ‘Geospatial methods of clustering leprosy case data for effective rollout or implementation of both PEP and new case detection initiatives’ by UK Aid-Department for International Development (DFID) through the Task Force for Global Health. The funders had no role in study design, data collection and analysis, data interpretation, decision to publish, or preparation of the manuscript.
Contributorship statement including name of guarantor
ATT (guarantor), WHB, JHR and DJB designed the study. AC, AK, NB and BS, coordinated the data collection process in Nepal. AC and ATT cleaned the data. ATT designed and performed the data analyses and data visualisation. ATT created the maps in Figures 2, 3, 4, 5 and S1. ATT drafted the paper. ATT, WHB, JHR, and DJB revised the draft paper. All authors read and approved the final manuscript.
Patient consent statement
No patient consent was required, though verbal consent to collect the GPS coordinates was obtained. For this study, patient’ information has been retrieved from the national register and a copy of the dataset has been anonymized to perform the analysis by the first author.
Data sharing statement
Data used for this study was collected as part of the COR-NTD project. The supporting data for this article can be obtained from the corresponding author on request.
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