Detection of previously undetected leprosy cases in a defined rural and urban area of Maharashtra, Western India

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1 Lepr Rev (2009) 80, Detection of previously undetected leprosy cases in a defined rural and urban area of Maharashtra, Western India VANAJA PRABHAKAR SHETTY*, UDAY HARIBHAU THAKAR**, ETHELDREDA D SOUZA***, SUNIL DATTATRAY GHATE*, SWARAN ARORA*, RIDDHI PRAKASH DOSHI*, ANJU VILAS WAKADE* & DONNA VASANT THAKUR*** *The Foundation for Medical Research, Worli, Mumbai, India **Kushth Nivaran Samiti, Panvel, India ***Lok Seva Sangam, Mumbai, India Accepted for publication 20 November 2008 Summary Introduction Leprosy has been a major public health problem in India for centuries. In India, between 2001 and 2005, the prevalence of leprosy was reduced by 80%. This sharp decline in the prevalence of leprosy alongside the cessation of active surveillance for detection of leprosy cases has raised a sense of alarm in the scientific community. Materials and methods This is a total population survey aiming to estimate the prevalence of undetected active cases of leprosy in the community in defined rural (Panvel Taluka, Raigad District) and urban (M-East Ward, Mumbai) areas by health workers from Kushth Nivaran Samiti (Panvel) and Lok Seva Sangam (Mumbai). Those provisionally diagnosed with leprosy were subjected to an independent verification using clinical, bacteriological and histopathological investigations at the Foundation for Medical Research. Findings A population of 196,694 and 600,247 was covered in defined rural and urban areas respectively. In the rural area on examining 178,646 individuals, 120 provisionally diagnosed leprosy cases were detected, of which 65 were paucibacillary (PB) and 55 were multibacillary (MB) based on the WHO operational classification used by health workers at field level. In the urban area, of the 512,434 individuals who were examined, 134 provisionally diagnosed leprosy cases were detected with 92 PB and 42 MB cases. Among the clinically confirmed cases, 35 6% (32/90) and 34 9% (36/109) in rural and urban areas respectively were children. Conclusions There are large numbers of undetected leprosy cases in the community with a high proportion of MB patients and children among them. This indicates active transmission pointing to the need for a paradigm shift in leprosy care services and control programme. Correspondence to: V.P. Shetty, The Foundation for Medical Research, 84-A, R.G. Thadani Marg, Worli, Mumbai , India (Tel: þ ; Fax: þ ; fmr@vsnl.net, fmr@fmrindia.org) /09/ $1.00 q Lepra

2 Detection of previously undetected leprosy cases in India 23 Introduction The World Health Organization chose prevalence as the measure for leprosy morbidity due to the insidious onset, long incubation period and chronic nature of leprosy. 1 Based on historical experience from Scandinavian and Western European countries, leprosy elimination was defined as less than one leprosy case per population since it was believed that at this level the incidence of leprosy infection would be reduced leading to natural extinction of the disease. 2 Despite various National Health Programmes working vigorously to bring down the leprosy prevalence to meet the World Health Assembly s resolution to eliminate leprosy as a public health problem by the year 2000, the single largest impact on global prevalence of leprosy was by WHO s decision to reduce the treatment period for leprosy patients from 24 to 12 months. 1,3,4 With over 122 countries considered to be endemic for leprosy in 1985, leprosy control took a massive leap in two decades achieving global elimination of leprosy at country level in Leprosy has been a major public health problem in India for centuries. In the 1980s, India had about 3 million registered cases of leprosy. In 2000, India was among the 12 countries with a prevalence rate above elimination level and accounted for 64% of the global burden of leprosy cases. 6 The integration of the vertical National Leprosy Elimination Programme (NLEP) into the general health services in India was initiated in In 2006, about 0 1 million new cases of leprosy were reported by India which accounted for 56% of the global burden of leprosy cases. 7 The annual detected cases plunged from 473,685 in 2002 to 161,457 in In India, between 2001 and 2005, the prevalence of leprosy was reduced by 80%. 8 This mammoth feat was accomplished following massive efforts by the Government of India. This sharp decline in the prevalence of leprosy alongside the cessation of active surveillance for detection of leprosy cases by the government health systems, as per the directives of the latest strategy of the World Health Organization, has caused a sense of alarm in the scientific community. With an incubation period of 2 10 years and 5% of the general population being nasal carriers of M. leprae DNA in leprosy endemic countries, it is difficult to halt the transmission of leprosy and hence the phenomenon of leprosy elimination is under question The need for further scrutiny of the actual burden of leprosy was identified by international organisations. In view of its vast experience in the area of leprosy research and patient care along with laboratory capacity, the Foundation for Medical Research (FMR) undertook an investigation into the magnitude of actual leprosy morbidity at community level. This study aimed at detecting the undetected active cases of leprosy in the community and determining the actual prevalence rate in a rural and urban setting of Maharashtra. Additionally, it compares the clinical, bacteriological and histopathological findings in leprosy patients in both settings. Histopathological examination was performed in order to classify patients based on their histopathological features, which could vary from the clinical classification where the latter is likely to lead to aberrant treatment.

3 24 V. P. Shetty et al. Materials and Methods STUDY AREA The state of Maharashtra has an estimated population of 111,443,362. A total of new leprosy cases were detected in Maharashtra bringing the new case detection rate to per 100,000 and prevalence of leprosy to 0 71 per population. 13 For this study one rural and one urban area within Maharashtra state located in Western India were chosen. These areas were chosen due to the presence and outreach of the field organisations in the respective communities. RURAL PANVEL TALUKA OF RAIGAD DISTRICT We included rural areas of Panvel Taluka, 1 of Raigad district, which had a population of 196,694, in this study. 2 The study area consisted of areas catered to by five primary health centres. A primary health centre represents the second tier of the three tier rural public health care system in India and caters to a population of about to as per the population norms of the Ministry of Health and Family Welfare. In Raigad, the prevalence rate of leprosy is 1 37 per population according to the latest prevalence figures published by the government of India. 13 M-EAST WARD OF THE MUNICIPAL CORPORATION OF GREATER MUMBAI Mumbai city has 24 administrative units of the Municipal Corporation of Greater Mumbai (A-T) called wards. M-East ward located in the north-eastern part of Mumbai was investigated in this study. The study area with a population of 600,247 was stratified into nine areas based on the health posts catering to them and analysis was conducted accordingly. A health post is the urban counterpart of a primary health centre which caters to a population of about The prevalence rate of leprosy in the health posts included in the present study as reported by the health posts was 0 9 per STUDY DESIGN This was a total population survey conducted in a defined area and aimed to estimate the prevalence of undetected active cases of leprosy in the community in the rural and urban region. A primary house-to-house survey was conducted from June to September Prior to the survey, training was conducted for the 71 health workers (10 health supervisors and 61 field workers) and 35 health workers (5 supervisors and 30 field workers) from both the rural and urban areas respectively. Initially three orientation sessions were conducted for field supervisors at FMR followed by a 3-Day training for the field workers at field level. Field workers worked in teams of two consisting of one male and one female. Each team covered about 12 to 15 households per day. During this survey, trained health workers from Kushth Nivaran Samiti and Lok Seva Sangam respectively were involved in screening the population within their respective rural and urban areas to detect all active undetected cases of leprosy. Following this a mop-up survey was conducted in October November 2007 to 1 A taluka is a subdivision of a district, a group of several villages organized for revenue purposes. 2 The population covered in this survey is stable and migrants were eliminated. Migrant was defined as any person residing in the study area for less than a year.

4 Detection of previously undetected leprosy cases in India 25 cover the households that had been missed during the first round of the survey. All the cases detected by the health workers were referred to the medical facility of Foundation for Medical Research (FMR) situated in the project areas where they underwent clinical confirmation. The provisionally diagnosed new and active old and relapse cases of leprosy, which were not on treatment, were subjected to an independent verification using clinical, bacteriological and histopathological investigations. The provisionally diagnosed leprosy cases presenting to the FMR medical facility were given a semi-structured interview schedule by FMR staff following informed consent. The semi-structured interview schedule enquired into the sociodemographic details of the patients, signs and symptoms and duration of symptoms, awareness regarding leprosy and delay in diagnosis. CLINICAL AND NEUROLOGICAL EXAMINATION The provisionally diagnosed leprosy cases underwent detailed clinical and neurological examination by physicians from FMR with more than 10 years experience in diagnosing and treating leprosy patients. Body charting to include size, number and location of skin patches was undertaken. Neurological examination included palpation of all the major nerves trunks to assess enlargement and tenderness. Touch sensibility was tested with a standard set of five coloured Semmes Weinstein monofilaments to assess the loss of sensation and grading of disabilities. 14,15 Reaction episodes, if any, and their types were also recorded. The patients were classified into PB and MB groups by the physicians based on the number of skin lesions and/or nerves involved. BACTERIOLOGICAL AND HISTOPATHOLOGICAL EXAMINATION A slit skin smear was performed using sterile scalpel blades by trained paramedical staff using standard techniques. The air-dried and heat-fixed smear was stained by Ziehl Neelson Carbol Fuschin and graded as per Ridley s scale for bacteriological index. 16 The patients who were diagnosed as having leprosy clinically were examined histopathologically. After taking informed consent, biopsies were obtained at the FMR medical facility from clinically confirmed patients by an experienced dermatologist in its operating theatre. Biopsies of involved nerves were obtained from pure neural leprosy patients at the operating theatre of the Foundation for Medical Research, Mumbai under local anaesthesia by a plastic and reconstructive surgeon. The biopsies thus obtained were fixed in formol Zenker and embedded in paraffin. Sections stained by Trichome modified Fite feracco (TRIFF) 17 were examined for load of acid fast bacilli and presence and type of inflammatory granulomas and further histopathological classification was performed using Ridley-Jopling scale. 18 The smears and biopsies were examined by a senior scientist at FMR and in doubtful cases histopathology was ascertained by a renowned pathologist from a tertiary hospital in Maharashtra. SECONDARY DATA FROM RURAL AREA In addition to the primary survey, health workers from the rural survey areas collected information regarding the cases registered with the primary health centres as well as three private physicians (chosen based on key informants from the study area). This data was

5 26 V. P. Shetty et al. verified by FMR staff and any overlap with the primary data was eliminated. This data was expected to contribute in minimising the inadvertent gaps in the community surveys. In the urban area, the number of registered leprosy cases from the health posts was obtained by health workers. The data from the private sector in the urban area could not be obtained due to the sheer large numbers of registered and unregistered medical practitioners in this area. A preceding detailed situation analysis would be warranted in order to obtain data from private practitioners in the urban area. ETHICAL CONSIDERATION The study received clearance from the Institutional Ethics Committee of the Foundation for Medical Research. The head of the household was explained the purpose of the survey and verbal consent obtained by health workers during the survey. Prior to examination verbal consent was obtained on an individual basis. Written informed consent was obtained from patients for biopsy as and when it was performed. Once the diagnosis of leprosy was established, patients were guided to the respective primary health care centres run by the government where free treatment for leprosy is available for treatment. Alternatively based on the convenience of the patients, the FMR clinic dispensed multidrug therapy as per WHO- NLEP guidelines. Reactions or neuritis (if any) were treated with appropriate drugs by the physicians using standard NLEP guidelines. 19 Results UNDETECTED CASES OF LEPROSY IN RURAL AND URBAN AREAS From about 0 2 million covered by the household survey in the rural region, 90 8% were examined by health workers. The proportion of adult males, adult females and children examined were proportionate to the number enumerated in the respective groups. Hence no selection bias could be evinced. Of them adult males, adult females and children 3 comprised of 37 88, and 17 47% respectively. Table 1 depicts the area wise number of leprosy cases detected in the rural region and the distribution of PB and MB cases along with the area wise prevalence of leprosy. About 85% of the urban population of 0 6 million was examined by health workers. In the population under study adult males, adult females and children comprised of 26 71, and 45 46% respectively. The number of individuals examined in each of these groups was proportionate to the number enumerated. Table 2 shows the area wise distribution of MB and PB cases in the urban region along with the prevalence rate of leprosy within each area. In the rural region, health workers detected 120 active cases of provisionally diagnosed leprosy in the rural population whereas in the urban region they detected 134 cases of leprosy. CLINICAL FINDINGS Overall 97 out of 120 and 116 out of 134 provisionally diagnosed cases in the rural and urban areas respectively underwent clinical examination. The remaining patients could not be examined due to operational reasons like distance and time of operation of the clinic, patient 3 For this study, child was defined as any person with age less than 14 years.

6 Table 1. Rural Survey findings (area wise) Detection of previously undetected leprosy cases in India 27 Active cases Survey area Enumeration Examination MB PB Total Prevalence rate per Gawan Apta Nera Wavanje Ajivali Total 196, , not presenting to the clinic for examination during the study period and patient preferring to seek care elsewhere. On clinical examination, all 97 rural provisionally diagnosed leprosy cases were confirmed with leprosy. Amongst these, three were treatment dropouts and four were relapses. Of the 90 newly detected leprosy cases in the rural population, adult male, adult females, children cases consisted of 32 (35 56%), 26 (28 89%) and 32 (35 56%) respectively. Similarly, of the urban region, 109 new cases of leprosy were detected along with three relapses, one treatment dropout. The findings in three patients did not confer to leprosy. The final diagnosis of leprosy was established following clinical examination by physicians. The cases were stratified based on clinical characteristics as represented in Table 3. Among the single skin lesion cases, a considerable proportion had facial lesions (36% in rural and 42% in the urban). The proportion of multibacillary leprosy cases was higher in the rural population (, 48%) compared to the urban (, 30%). Overall, 6% of cases comprised of pure neural cases of leprosy. Most of the pure neural leprosy cases (11/12) demonstrated involvement of more than one nerve and were hence classified as multibacillary cases. The prevalence rate of undetected leprosy cases based on clinically confirmed cases and excluding single skin lesion (SSL) cases is represented in Table 4. Since the government of India does not include SSL cases as leprosy cases, prevalence following exclusion of single skin lesion leprosy cases has been presented. The prevalence of Table 2. Urban survey findings (area wise) Active cases Survey area Enumeration Examination MB PB Total PR Deonar Colony 1,01, Mankurd Baiganwadi Shivaji Nagar Nimoni Bagh Lotus Colony Shatabdi Hospital Ayodhya nagar Cheeta Camp Total 6,00,247 5,12,

7 28 V. P. Shetty et al. Table 3. Clinical characteristics of newly diagnosed leprosy patients Number of skin lesions Rural Urban Single lesion (SSL) lesion lesions Pure neural (PN) 5 7 Total undetected cases of leprosy in the community in the rural and urban areas was found to be 5 04 and 2 13 per respectively; 11/32 (34 37%) children in rural areas and 14/36 (38 88%) children in the urban area were under the age of 10 years; 5/32 (15 62%) and 5/36 (13 89%) children in the rural and urban areas respectively had age #5 years. Clinicians used the standard WHO scale for disability grading in leprosy patients in the clinically confirmed leprosy cases. Sixteen patients (18%) from the rural area and nineteen (17%) from urban area had disabilities of either grade one or two. In addition it was observed, the proportion of patients having grade two disability (21/35) was high (Table 5). BACTERIOLOGICAL FINDINGS Overall, 182 clinically confirmed cases of leprosy underwent smear examination. Amongst the cases with.5 skin lesions, 33% were found to be smear positive. All the paucibacillary and pure neural cases were smear negative. The proportion of smear positive MB cases was higher in the urban population. About 75% of the smear positive patients had a bacterial index of 3 þ or more (Table 6). HISTOPATHOLOGICAL FINDINGS Of the 199 new patients, 138 (69%) were biopsied and studied using histopathological parameters. An important finding was that 12 5% (6/48) of single lesion cases showed cellular characteristic features of BB BL type of leprosy whereas 35% (21/60) of clinically defined MB cases with more than five skin lesions were histopathologically characteristic of BT leprosy cases. Histopathological diagnosis proved inconclusive in five cases. One of these cases was likely to be a case of follicular eczema while the other three were likely cases of Table 4. Stratified prevalence of leprosy Prevalence rate of undetected leprosy cases per Prevalence rate by category Rural Urban PR of clinically confirmed cases PR after excluding single skin lesion cases

8 Table 5. Grade of disability among leprosy cases in rural and urban areas Detection of previously undetected leprosy cases in India 29 Grade of disability Rural Urban Grade Grade Grade xerosis/polymorphous light eruptions. In addition, one case could not be histopathologically classified (Table 7). SECONDARY DATA The number of diagnosed leprosy cases obtained from Primary health care centres and private physicians from the rural study area was 39 and 45 respectively. The medical officers at the Primary health centre and private physicians used standard guidelines for diagnosis of leprosy. The number of leprosy cases reported by the PHCs in rural area and health posts in the urban area in the years and is represented in Table 8. Discussion As per the Global Strategy for Further Reducing the Leprosy Burden and Sustaining Leprosy Control Activities , National Leprosy Programmes are urged to encourage people to come forward for treatment, and recommends limiting leprosy services to health facilities. 17 A voluntary reporting system for leprosy patients has some inherent problems related to the low level of community awareness, high social stigma, atypical skin lesions and late presentation of neurological symptoms. On the contrary, active case searching from the community facilitates early case detection thereby reducing the risk of permanent disabilities and interrupts the transmission. Active case detection reveals that there are a large number of previously undetected leprosy cases in the study population. A recent study from north-western Bangladesh depicted similar findings with a prevalence of previously undiagnosed leprosy of about (13 1 per population) compared to the registered leprosy cases (2 31 per population). 20 Another study in Brazil showed that 28 4% of leprosy cases in the community were not Table 6. Bacteriological findings in relation to clinical sub-class Smear examination Smear positive Smear negative Not done Total Number of lesions Single lesion Pure neural Total

9 30 V. P. Shetty et al. Table 7. Clinical and histopathological classification of cases Ridley Jopling classification BT BB BL LL Indeterminate Non-specific Clinical classification SSL (n ¼ 48) lesion (n ¼ 27) lesions (n ¼ 60) Pure neural (n ¼ 3) Total (n ¼ 138) identified by the health system between A sample survey from Mumbai showed that 86% of the 79 newly detected cases did not report to the health systems despite having skin patches. This high proportion of undetected cases was interpreted as a limitation of the impact of IEC activities. 22 The National Leprosy Elimination Programme projected the presence of Grade 2 disability in leprosy patients to be about 2 4%. 15 However, in this study it was elicited that the prevalence of grade 2 disability was up to 12% in newly detected cases of leprosy. A study in Delhi and Kolkata also showed a high proportion of patients with Grade 2 disability. 23 The World Health Organization s Global Strategy for Further Reducing the Leprosy Burden and Sustaining Leprosy Control Activities does not require smear examination for diagnosis of leprosy. A majority of the smear-positive patients (19/195) in this study were shown to have a high bacterial index (BI $ 3). A facility based study in an urban population of north India showed a prevalence of high bacterial index in 20% of newly diagnosed MB cases of leprosy. 23 A considerable proportion of smear positive leprosy patients (33%), the significant proportion of Grade two deformity and high burden of leprosy in children (45 6%) Table 8. New cases reported by PHCs and Health posts in study area during and Area MB PB Total MB PB Total Rural Apta Ajivali Nera Vavanje Gawan Urban Baiganwadi Mankhurd Lotus colony Shatabdi Cheeta camp Deonar colony Ayodhyanagar Nimoniya baug Shivaji nagar

10 Detection of previously undetected leprosy cases in India 31 implies likelihood of an extended active transmission of leprosy in the community. Cumulatively these findings point to impaired access to the health services for the population or its delayed utilisation. It is evident that a large proportion of newly detected patients (71/199) were single skin lesion cases. More importantly, a reasonable proportion (13%) showed BB BL leprosy on histopathological examination. The NLEP curtailed registration of patients with single skin lesions by 2005 under the premise of misdiagnosis of other dermatological conditions as leprosy. 11 This not only deprives the patients of timely treatment and prevention of deformity but also promotes transmission of leprosy in the community through multibacillary single lesion cases. POLICY IMPLICATIONS The wide gap between the estimated prevalence of leprosy obtained by active case detection and projected prevalence obtained by passive case reporting underscores the efficiency and need for active case detection in leprosy in order to obtain the actual burden of disease. However in view of limited resources in the public health system it may not be possible to undertake an active case detection in the entire population. Alternative methods may need to be considered. 24 This study highlights the presence of a large number of undetected cases of leprosy in the community in Panvel and Mumbai. Numerous studies have indicated the occurrence of leprosy in clusters. The high burden of leprosy in Panvel could be the indication of an evolving cluster or pocket of leprosy due to various unknown biosocial factors which need further investigation. The high degree of active transmission of leprosy in the study population is indicated by the large number of children affected by leprosy. The high proportion of multibacillary cases and Grade 2 deformity cases are also pointers to the gravity of the situation. Thus a policy for active case detection, in selective areas demonstrating higher burden of child leprosy and Grade 2 deformity, would aid in the estimation of the real burden of leprosy. This would help in provision of timely and adequate treatment and rehabilitation support to the patients. The single skin lesion patients are classified as paucibacillary and often not registered or treatment is withheld under the condition of inadequate evidence of leprosy. However a considerable proportion of that group was found to be either suffering from borderline or borderline lepromatous leprosy on histopathological examination of the skin biopsies indicative of high risk of transmission. This highlights the need for caution during handling of the issue of single skin lesion cases at clinical and policy level. One of the cornerstones of National Leprosy Elimination Programme is information, education and communication (IEC) in the community. The government has also partnered with various non-governmental organisations in order to increase the level of awareness with regard to leprosy at community level. Despite significant financial and human investment by the Government of India over decades, the impact of IEC seems to be limited. In the course of this survey, it was also documented that a major proportion of individuals affected by leprosy had not even heard about leprosy before the survey was conducted. In addition, a high percentage of patients did not seek care for leprosy for over a year after appearance of initial symptoms of leprosy. (Data not shown) These findings emphasise the need for strengthening of this component.

11 32 V. P. Shetty et al. This delayed presentation of leprosy cases to the health system could be indicative of other barriers in access to health care like physical, social and economic in addition to the information barrier highlighted above. (Data not shown) An investigation of the situation with respect to access to health care for leprosy patients including the quality of services would be crucial in view of the current scenario. Acknowledgements We thank Swiss Emmaus Leprosy Relief for funding this study. Dr. Thomas von Stamm from the Swiss Emmaus Leprosy relief and Dr. Dinesh Jain (Regional Medical Co-ordinator), Swiss Emmaus Leprosy relief have been very supportive throughout the course of the study. We thank the project team (Foundation for Medical Research: Ramchandra Chile, Harish Poojari. Kushth Nivaran Samiti: Mr. Suresh Kalekar, Dynaneshwar Kholaghade and health workers. Lok Seva Sangam: Dr. Manjunath Kini and health workers). We would like to acknowledge Dr. Nerges Mistry, Director, Foundation for Medical Research for her inputs from the conceptualisation of the study until its completion. Our hearty thanks to Dr. K Ramachandran for his help in early discussion with respect to study design, inputs in statistical analysis and suggestions for this manuscript, Dr. K V Desikan for confirming the histopathological diagnosis and Dr. Sheela Rangan for her inputs in operational aspects of the study. We would also like to express our gratitude towards the patients who participated in this study. References 1 World Health Assembly. Elimination of leprosy: resolution of the 44th World Health Assembly. Geneva: World Health Organization, (Resolution no WHA 44.9). 2 Durrheim DN, Spearre R. Global leprosy elimination: time to change more than elimination target date. J Epidemiol Community Health, 2003; 57: World Health Organization. Shortening duration of treatment of multibacillary leprosy. Wkly Epidemiol Rec, 1997; 72: World Health Organization. 7th Expert Committee on Leprosy. May June Geneva. Available at accessed on 22nd August Website of the World Health Organization. html, accessed on 7th May Announcement: India achieves national elimination of leprosy. Ind J Lepr, 2006; 78: Joshi PL, Barkakaty BN, Chakma JK. Recent developments in elimination of leprosy in India. Ind J Lepr, 2007; 79: World Health Organization. Global leprosy situation Wkly Epidemiol Rec, 2006; 81(32): R c letter 25976/lep. V/2005 dated Office of the directorate of health, Andhra Pradesh, Hyderabad. 10 Klatser PR, van Beers S, Madjid B et al. Detection of Mycobacterium leprae nasal carriers in populations for which leprosy is endemic. J Clin Microbiol, 1993; 31: Noordeen S. The epidemiology of leprosy. In: Hastings R (ed). Leprosy. Churchill Livingstone, Edinburgh, 1994, pp Lockwood DNJ. Leprosy elimination a virtual phenomenon or a reality? BMJ, 2002; 324: Government of India. Ministry of Health and Family Welfare. National Leprosy Elimination Programme Report, March New Delhi. 14 Bell Krotowski JA. Pocket filaments and specifications for the Semmes- Weinstein monofilaments. J Hand Ther, 1990; 3: World Health Organization. Global Strategy for Further Reducing the Leprosy Burden and Sustaining Leprosy Control Activities , Geneva.

12 Detection of previously undetected leprosy cases in India Ridley DS. The bacteriological interpretation of skin smears and biopsies in leprosy. Trans Roy Soc Trop Med and Hyg, 1955; 49: Wheeler E, Hamilton E, Harman D. An improved technique for the histopathological diagnosis and classification of leprosy. Lepr Rev, 1965; 36: Ridley DS, Jopling WH. Classification of leprosy according to immunity A five group system. Int J Lepr, 1966; 34: World Health Organization Expert Committee on Leprosy. WHO Technical Report Series No. 874, Moet FJ, Schuring RP, Pahan D et al. The prevalence of previously undiagnosed leprosy in the general population of Northwest Bangladesh. PloS Neglected Tropical diseases, 2008; 2: Grossi, MAF, Moschioni, C, Lambertucci, JR, Antunes, CMF. Estimation of hidden prevalence of leprosy during the period , in Minas Gerais, Brazil. Proceedings of the 17th International Leprosy Congress, Hyderabad, February Kingsley S. Sample Survey in Mumbai under the auspices of Municipal Corporation of Greater Mumbai. Session 2, National workshop on Strategies for new case detection during integration phase: experiences across Maharashtra. ALERT India. 11th October Rao PSS, Jayakumar S, Vijayakumar D, Joshua J. Delayed presentation of leprosy at 2 urban centres in India. Proceedings of the 17th International Leprosy Congress, Hyderabad, February Gupte MD, Murthy BN, Mahmood K et al. Application of lot quality assurance sampling for leprosy elimination monitoring examination of some critical factors. Int J Epidemiol, 2004; 22: