Background The global elimination of leprosy transmission by 2030 is a World Health Organization (WHO) target. Nepal’s leprosy elimination program depends on early case diagnosis and the performance of health workers and facilities. The knowledge and skills of paramedical staff (Leprosy Focal Person, LFP) and case documentation and management of health facilities is therefore key to the performance of health care services. Methods The performance of health workers and facilities was evaluated through a combined cross-sectional and retrospective study approach of 31 health facilities and their LFPs in Dhanusa and Mahottari Districts in Madhesh Province. An average of 6 patients (paucibacillary, PB, or multibacillary, MB) per health facility registered within the 2018/2019 fiscal year were also enrolled in the study. LFP knowledge (e.g., of the three cardinal signs) and skills (e.g., nerve palpation) and facility processes (e.g., record keeping) were scored (e.g., 0, 1) and then rescaled to a proportion, where 1 is perfect. Internal benchmarking was used to guide performance management. Results The overall performance of health care services was 0.43 (95% confidence interval (CI), 0.40-0.46), ranging from 0.33 (95% CI, 0.25-0.40) for LFP knowledge and skills, 0.37 (95% CI, 0.32-0.43) for documentation and 0.60 (95% CI, 0.58-0.61) for case management scores of health facilities. Leprosy-related training was significantly related to the knowledge and skill of the health workers. All identified cases (n =187) adhered to the complete treatment and release after treatment (RFT) scheme, out of which 84.5% were satisfied with the service they were provided. Leprosy disability and Ear Hand and Feet (EHF) scores were not significantly reduced in treated patients, but counseling by LFPs significantly improved cases’ positive belief and practices regarding self-care. Conclusion Overall leprosy care performance was low (43%) and can be improved by evidenced-based training, onsite coaching, monitoring, and supervision to facilitate leprosy transmission elimination. The results highlight many of the challenges facing leprosy elimination programs.

Background Nepal has achieved and sustained elimination of leprosy as a public health problem since 2009, but 17 districts and 3 provinces have yet to eliminate the disease. Pediatric cases and grade-2 disabilities (G2D) indicate recent transmission and late diagnosis respectively, which necessitate active and early case detection. This operational research was performed to identify approaches best suited for early case detection, determine community-based leprosy epidemiology, and identify hidden leprosy cases early and respond with prompt treatment. Methods Active case detection was performed by: house-to-house visits among vulnerable populations ( n= 26,469), contact examination and tracing ( n= 7,608) and screening prison populations ( n= 4,428) in Siraha, Bardiya, Rautahat, Banke, Lalitpur and Kathmandu districts of Nepal. Results New case detection rates were highest for contact tracing (250), followed by house-to-house visits (102) and prison screening (45) per 100,000 population screened. However, cost per case identified was cheapest for house-to-house visits (Nepalese rupee (NPR) 76,500/case), then contact tracing (NPR90,286/case) and prison screening (NPR298,300/case). House-to-house and contact tracing case paucibacillary/multibacillary (PB:MB) ratios were 59:41 and 68:32; female/male ratios 63:37 and 57:43; pediatric cases 11% in both approaches; and G2D 11% and 5% respectively. Developing leprosy was similar among household and neighbor contacts (Odds ratios (OR)=1.4, 95% confidence interval (CI), 0.24-5.85) and for contacts of MB versus PB cases ( OR= 0.7, 0.26-2.0). Attack rates were similar among household contacts of MB cases (0.32%, 0.07-0.94%) and PB cases (0.13%, 0.03-0.73) and neighbor contacts of MB cases (0.23%, 0.1-0.46) and PB cases (0.48%, 0.19-0.98). BCG vaccination with scar presence had a significant protective effect against leprosy ( OR= 0.42, 0.22-0.81). Conclusions The most effective case identification approach here is contact tracing, followed by house-to-house visits in vulnerable populations and screening in prisons. The findings suggest hidden cases, recent transmission, and late diagnosis in the community exist and highlight the importance of early case detection.