A recent study by an international group of researchers has revealed some unpleasant reality of a government-aided program in Bihar for diagnosing leprosy and has estimated the efficiency of an approach that can promote accurate diagnosis of the disease. The researchers belonged to the Damien Foundation India Trust, Damien Foundation, Belgium, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, International Union against Tuberculosis and Lung Disease, France, and Sri Manakula Vinayagar Medical College and Hospital, Puducherry. The results of the study were published in the journal PLOS Neglected Tropical Diseases.
Leprosy, a disease that affects the skin and peripheral nerves, is a chronic infection caused by the bacteria Mycobacterium leprae. India has the highest burden of leprosy with about 60% of the world’s new leprosy cases reported each year. To keep a check on the spread of the disease, the National Leprosy Eradication Programme (NLEP) introduced a yearly campaign in 2016 to detect leprosy cases in areas where the infection is prevalent. However, a significant challenge with this step was the high numbers of ‘false positives’ where individuals are erroneously diagnosed with leprosy.
In the current study, the researchers estimated the proportion of such false positives under the leprosy detection campaigns of 2016 and 2018 in eight primary health centres (PHCs) from four districts of Bihar. Bihar is one of the states with the highest leprosy burden with 15-20% of the country’s new cases reported here every year.
The researchers found that although there was a 62% decline in the total number of leprosy cases diagnosed in those eight primary health centres between the two years, the detection was not accurate. About 30% of cases diagnosed in 2016 were false positives.
“False positive diagnosis leads to unnecessary medication, causes stigma, isolation, loss of employment and discrimination that can lead to considerable mental trauma and agony in the patients and their families”, say the authors about the problems associated with the wrong diagnosis.
The researchers introduced an approach called appreciative inquiry before the 2018 campaign and involved healthcare staff from PHCs. “Appreciative inquiry is a process which shifts the focus of programme or organisation from problem identification, defensiveness and denial of facts towards the discovery of programme strengths and building on what works well in the given setting and context”, explain the authors. This approach served as motivation for staff and helped in the sustainability of public health programmes in low and middle-income countries.
After the appreciative inquiry was introduced, the researchers observed that the number of false diagnoses had reduced to about one in four cases (23.4%) in 2018, as compared to about one in three cases (29.6%) in 2016. Although this improvement is not statistically significant, it indicates the potential advantages of this approach, say the researchers. “Appreciative inquiry could have played a role in reducing the false positive diagnosis, and the change could have happened through the re-trainings, supportive supervision and monitoring”, they argue.
The findings strongly support the need for validation of diagnosis processes to address the drawbacks of diagnosis campaigns like the Leprosy Case Detection Campaign (LCDC).
“We strongly believe that the validation exercise conducted by the Damien Foundation India Trust in the limited number of primary health centres helped identify an important operational problem, and therefore this needs to be done in all other districts and other states of India”, conclude the authors.