More than a decade after India eliminated leprosy, the disease continues to be a thorn in the side of Indian health policy. As the disease potentially shows signs of a resurgence, we may soon have to rethink its status as “eliminated”.
A disease is considered eliminated when its prevalence is reduced to less than one case per 10,000 persons. This definition is critical to understanding that elimination does not necessarily mean that the disease is gone for good. It is only when a disease is defined as eradicated that it is established as having no new cases.
An ancient disease once again rearing its head?
The Central Leprosy Division of the Union Health Ministry reported the detection of 135,485 new leprosy cases in India in 2017. This means that, every four minutes, somebody was diagnosed with leprosy in India. The media is currently rife with claims that this is nowhere even close to being considered eliminated.
Given the current population of India, cited in 2017 as being 1.36 billion, these additional 135,485 cases would establish a rate of one person per 10,045 individuals who have contracted leprosy. While this figure falls within the accepted rate for elimination, it is worth reminding that this figure is just the new cases detected within 2017. This potentially entails that the overall figure for leprosy in India is now above the accepted limit for elimination criteria.
However, government officials dispute the idea of a resurgence. “No, leprosy is not rising in India, the numbers are rising because we are detecting more cases,” Anil Kumar, deputy director general for leprosy at the Ministry of Health & Family Welfare said in comments to IndiaSpend.
The Wire suggests that, as India was receiving funding from the World Health Organization (WHO) to eliminate leprosy, the government was under extreme pressure to produce results. They suggest that misrepresentation and neglect may have been contributing factors to the achievement of the elimination status in order to more rapidly show progress.
To do this, experts have suggested that active case-seeking was stopped, self-diagnosis was not counted towards the overall figure and single-lesion cases — deemed as a less serious incident of the disease — were also ignored.
As the 2017 figures suggest, even new cases of the disease fall just short of stepping over the elimination status, making it an unlikely prospect that the disease was indeed eliminated in 2005. That is, unless leprosy is, in fact, showing a resurgence, which is currently being denied.
High population and elimination terminology
India suffers an issue unique to itself and China, this being the sheer size of the population. Terminology such as elimination where the classification is determined as a proportion of the population is reasonable for most countries as under elimination status the overall number of disease cases will indeed be low.
In India however, even when a disease is considered eliminated, the overall number of cases can number in the tens of thousands. To illustrate the point, despite leprosy being eliminated in 2005, India had the largest number of leprosy patients in the world. The WHO noted in 2016 that India accounted for sixty percent of new cases globally.
Promises of eradication go unfulfilled
Finance Minister Arun Jaitley pledged in 2017 that leprosy would be eradicated from India by 2018. As we are now seeing, this promise has been left unfulfilled. Media at the time reported that 127,334 new cases were detected across the 2015-2016 period, a lower figure than has now been given across 2017.
Studies are finding an increase in ‘heightened disability’ among the newly detected cases. An evaluation of the National Leprosy Eradication programme in late 2016 said that this indicated “that the cases are being detected late in the community and there may be several cases which are lying undetected or hidden”.
The review went on to say that “an active reservoir in the community which transmit the disease to [the] susceptible”. It also found a large number of children among those detected. These factors suggest that surveillance of the disease has been neglected and that disease cases are being allowed to progress before treatment is provided.
Anil Kumar contested these claims, saying that the increased prevalence of the disease can be attributed to increased surveillance. He cites a Leprosy Case Detection Campaign conducted by ASHAs in 163 endemic districts of India had screened 360 million people in 2016 and 700 million in 2017. Kumar suggested these campaigns account for the higher numbers of cases detected.
Increased surveillance is vital in bringing the disease closer to eradication as even a single individual who is left unaccounted for can spread the disease. While eradication goals of 2018 may have been overly optimistic, detecting such a large number of individuals with leprosy, and importantly, allowing access to treatment, could begin to stem the potential for a resurgence.