Insights from teams who have been working on contact tracing and found ways of making it successful.
When the WHO released their Global Leprosy Strategy 2021-2030, one of their four key pillars called for the sector to ‘scale up leprosy prevention alongside integrated active case detection’. A crucial part of that is contact tracing, both to help us identify new cases and to administer a post-exposure prophylaxis (PEP) to prevent the development of symptoms.
The available data suggests that contact tracing is going to be indispensable if we want to reach a world without leprosy transmission. Mass contact tracing efforts in Viet Nam have seen the country go from more than 1,400 cases per year in 2000 to around 40 cases in 2019, including zero child cases in 2018, 2019, and 2020. In other encouraging findings from northwest Bangladesh, a total of 1,985 new cases were found after screening the contacts of just 9,884 index cases.
Whilst the efficacy of contact tracing is not in doubt, there are still many countries and communities with limited experience of contact tracing. Over the coming pages we share the experiences of three TLM countries, Bangladesh, Nigeria, and Timor-Leste, who have found ways to overcome challenges surrounding contact tracing, as well as engaging government partners effectively with the process.
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In Bangladesh, 90-95 percent of the household contacts of each index case will be screened for leprosy by The Leprosy Mission. As well as this, around 30-40 of the surrounding households will be screened. We’ve found this to be a great source of finding new cases.
Of course, the extent of the case finding activities is dependent on local capacity. If there is local capacity, we aim to follow up with contacts once a quarter. Where there is not capacity, we will aim for once every six months. For us, this has proved to be the biggest source of new case detection.
In Timor-Leste, this process is a collaboration between the government health services and us. We aim to reach the household and neighbouring contacts of every single index case. We do our best to train the government health workers so that they can identify new cases themselves, although there are many who are not confident to do that, so our team still does a lot of the contact tracing.
In just two of our high-endemic municipalities, these efforts allowed us to identify 80 new cases of leprosy between January and June 2021. In three of our low-endemic municipalities, we were seeing an average of two or three new cases a year. Once we started contact tracing in those communities, we found 18 new cases.
We have developed a household contact screening pathway. This pathway is activated every time an index case is identified and will be carried out by the General Healthcare Workers in the community.
The worker will agree a date to visit the index case, they will be introduced to the contacts, and they will seek permission (using a consent form) to do a screening. If the contact does not have leprosy, they will be provided with PEP. If they are found to have leprosy, they are provided with MDT. The workers will collect data on what they have seen and will send that to TLM Nigeria and the Government Leprosy Control Programme Unit.
© Ruth Towell
Covid-19 caused our project some problems. When there were big outbreaks of Covid-19 in a community in Timor-Leste, the government would initiate mass testing in the community. If a person tested positive for Covid-19, they would be moved to an isolation centre. This was a problem for us because we would arrive in a community and the community members would assume we were there to do Covid-19 testing and they would hide from us or refuse to be tested.
Clear communication around contact tracing for leprosy and increasing community awareness of this was important while we overcame this challenge.
Like many places around the world, a lack of leprosy expertise among community health workers was a problem. We’ve found they are much more confident about the contact tracing and diagnosis process when our teams are with them. Hopefully we can build this confidence so they can do the work on their own in time.
Capacity is always going to be a challenge for contact tracing. The cost is not just staff time, but also includes travel and accommodation. This is a reality that we have to face, but we know that contact tracing is one of the most effective tools we have. If we’re going to end leprosy transmission, we have to prioritise contact tracing, especially if it can be paired with PEP.
Another difficulty for us comes from working through the government systems. Sometimes they can be reluctant to register a certain number of new cases if they know they do not have the right amount of MDT to treat all the cases. It does not look good for them, so they can refuse to do report some cases until the next round of reporting.
We have a good relationship with the government services, so that helps us to work through this challenge.
There are two intersecting challenges for us. The first is a lack of government funding and the second is a dwindling leprosy expertise among health workers.
We have been able to handle both of these problems through our TLM-funded case finding projects, as well as the Ready4PEP project in collaboration with LTR. The Ready4PEP, project is a pilot of PEP implementation in Nigeria. We have been demonstrating to the government that contact tracing and PEP are going to help us dramatically drive down the numbers of new leprosy cases each year. There is a tangible sense of excitement about this within Nigeria, which is helping with our advocacy efforts.
The TLM funded case finding projects have also allowed us an opportunity to train health workers in the focus communities and increase their confidence in identifying and diagnosing new cases of leprosy.
Getting government ownership and enthusiasm for administering PEP has been the key to making these efforts successful. Demonstrating the potential success of the project was crucial.
© Ricardo Franco
This really would not be possible without close partnership with the government, as we recognise that they own the programme. We need to support the capacity building of the health workers and the lab technicians to bridge the gap in leprosy expertise and make this possible.
I would encourage others to demonstrate the power of contact tracing to their government partners and get them excited about the opportunities. Then set up a sustained training and mentoring system for the health workers and lab technicians so that leprosy becomes a part of their regular work.
We have also been partnering with traditional healers and patent medicine vendors. We have trained them to recognise leprosy and set up referral pathways through them.
We would agree that training local health workers is crucial for our programme. We have been working with our government partners to demonstrate that contact tracing is effective and that the WHO is making this a crucial part of leprosy work. Colleagues from WHO Southeast Asia have helped us make this case to the government.
We also invited some of the leprosy and NTD staff at the Ministry of Health to join us while we conducted contact tracing work. When they did the tracing themselves and saw that it worked, they took it a lot more seriously.
These discussions are giving us opportunities to move contact tracing forward. Through this, we’re able to increase training opportunities for local community workers. I’d encourage anyone else who is considering how to develop this work to maintain those good relationships with government partners. You need to be able to show them the potential impact, even if it means taking them into the field to see for themselves.
The WHO Global Leprosy Strategy 2021-2030 is already looking towards contact tracing, but many national strategies are not yet. We have to encourage and support governments to change their systems and incorporate contact tracing.
You should tell your government partners that, if they can invest money, the NGOs are in a position to offer our teams, our expertise, and our networks to help them make this a reality.
This is one of the very best ways to interrupt leprosy transmission. It simply has to be done if we are to eliminate leprosy.
