Dr Benedict Okoe Quao – National Leprosy Program Manager Outline

Global consultation with NLP managers, partners and affected persons on Global Leprosy Strategy 2021‒2030 1 Africa, Europe, Americas 26-29 October 2020

CONTACT TRACING: GHANA PERSPECTIVE

 Introduction

 Ghana: Leprosy Epidemiological Trends

 Strategies to enhance case detection in recent years

 Leprosy Contact Tracing in Ghana including timeline of changes

 New tools introduced to support contact tracing

 Analysis of Contact Tracing Data

 Analysis of Active Case Searches as comparison to Contact Tracing

 Conclusions

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Introduction

 Ghana Leprosy Service was established in late 1940s with primary aim of developing and implementing policies and programmes to reduce transmission of leprosy as well as its associated disabilities

 Ghana crossed EPHP threshold at National level in 1998; translated to all regional levels by 2005

 Gradual integration of activities within the general health services over the past 2 decades with NLCP (or rather NLEP) evolving to take up role in the Ghana Health Service (GHS).

 Predominant mode of case detection:- Largely passive

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Ghana – Leprosy Trends since 2000

1800 100.00%

1600 1569 90.00%

1389 80.00% 1400

Enhanced New 70.00% 1200 1090 Case Detection 60.00% 1000 over last couple 50.00% 820 815 803 of years 800 669 40.00% 623 594 560 547 600 520 471 30.00% 413 400 366 302 291 20.00% 258 276 279

200 10.00%

0 0.00% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Prev. NCD MB% G2D% Child%

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Why enhanced case detection?

 Important questions asked…

900,000 1,800 800,000 1,600 Global NCD Trend Ghana NCD Trend 700,000 1,400 600,000 1,200 500,000 1,000 400,000 800 300,000 600 200,000 400 100,000 200 - -

What was Ghana doing different? Ghana doing better than the world or we are under-detecting new cases?

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Strategies to enhance case detection

 Continuing with front-line health care worker training to enhance suspicion of cases

 Increasing Public Awareness to improve self-referral and therefore passive case detection  Leprosy Day Celebrations; Engaging Media directly

 Focused active case detection  Population-level active case searches (in 15 Anesvad-Supported Districts)  Reinvigorate contact tracing

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Contact Tracing in Ghana

 Historically, house-hold contacts identified as high risk group

 Past and present leprosy Strategic Plans have had “Intensifying case search especially in inaccessible areas, urban slums and rural areas, and amongst high-risk groups (household contacts)” as a key strategy

 Both patients and their contacts supposed to be put on surveillance

 Challenges pre-existing:  No clear guidelines in place  Not systematic; up to the officer/coordinator in question  No dedicated funding to support such activity

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Increasing momentum for contact tracing

• WHO finalizes first guideline for diagnosis, treatment & prevention of leprosy Jun. 2018 • Includes recommendation for SDR prophylaxis for contacts

• Annual Review and Planning Meeting for Regional Technical Officers, Ankaful, Ghana - 2019 Jan. 2019 • RTOs impressed upon to implement established contact tracing strategy

• Global Training of NLP Managers from priority leprosy-endemic countries, Bangkok, Thailand • PM in attendance; Recommendation: improve contact tracing at all levels within health system to support planned April 2020 mass preventive chemotherapy in post-2020 strategy

• Annual Review and Planning Meeting for Regional Technical Officers, Ankaful, Ghana – 2020 • Introduction of New tools – Register with contacts traced field; Contact Tracing Forms; Update of DHIMS-2 leprosy Jan. 2020 form including information on contact tracing

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Pre-existing Records of Contact Management

Examples of previous contact tracing recording

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Leprosy Case-Based Reporting Form

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 New Contact Tracing Forms

FormForm usedused forfor followlisting- up of patientscontacts (at for lower index level) patient

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Updated Register

UpdatedPrevious VersionVersion ofof RegisterRegister

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Analysis – Contact Enumeration/Examination

2015 2016 2017 2018 2019 2020* a. No of leprosy cases brought forward from prev. year 384 315 285 254 313 326 b. No. of New Leprosy cases detected in index year 302 291 258 276 279 153 c. No. of new cases who had contacts enumerated/ listed 64 53 41 65 87 92 Proportion of New leprosy cases** with contacts listed 21.2% 18.2% 15.9% 23.6% 31.2% 60.1% d. Total No. of contacts enumerated/listed 46 41 30 340 437 345 No of contacts per index case listed 0.72 0.77 0.73 5.23 5.02 3.75 e. Total No. of enumerated/listed contacts examined 46 41 30 333 431 313 Proportion enumerated contacts examined 100.0% 100.0% 100.0% 97.9% 98.6% 90.7% *Incomplete year data **Using new cases within index year as denominator

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Analysis – When examination is being done

2015 2016 2017 2018 2019 2020* January 5 1 0 29 7 14 February 14 1 2 9 199 54 March 7 15 2 21 23 27 April 3 1 3 7 16 21 May 2 3 7 8 14 36 June 2 0 6 46 32 45 July 3 4 0 84 8 33 August 1 3 2 83 19 34 September 1 2 1 12 95 31 October 1 2 1 8 8 18 November 2 8 2 9 4 0 December 5 1 4 17 6 0 *Incomplete year data

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Analysis – Who is examining contacts?

2015 2016 2017 2018 2019 2020* Regional Officer or leprosy coordinator 5 1 3 9 11 40 District DCO or coordinator 20 12 7 164 290 135 Sub-district DCO/FT or coordinator 13 20 9 50 107 106 HCW at primary care level 3 4 6 89 7 17 Other 5 4 5 21 16 15 Total 46 41 30 333 431 313 *Incomplete year data

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Analysis – Yield (Contact tracing)

2015 2016 2017 2018 2019 2020* e. Total No. of enumerated/listed contacts examined 46 41 30 333 431 313 f. No. of new cases of leprosy detected amongst examined contacts 0 0 0 1 2 3 g. No. of old/previously treated cases identified amongst enumerated/listed contacts during contact examination 0 1 0 2 2 2 Cumulative yield of new leprosy cases and previously treated leprosy cases amongst contacts 0 1 0 3 4 5 Proportion of examined contacts diagnosed with leprosy requiring treatment during contact examination 0.0% 0.0% 0.0% 0.30% 0.46% 0.96% New Case Detection Rate using examined using number of examined contacts as denominator (per million) 0.0 0.0 0.0 3003.0 4640.4 9584.7 Proportion of examined contacts either with a history of leprosy or diagnosed as a new case of leprosy during contact examination 0.0% 2.44% 0.0% 0.90% 0.93% 1.60% h. No. of index cases with history of leprosy amongst their contacts (dead or alive) 2 0 0 1 1 2 Proportion of index cases with history of leprosy amongst listed contacts 3.13% 0.0% 0.0% 1.54% 1.15% 2.17% *Incomplete year data Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Active Case-Searches (2018)

Description No. of cases confirmed of Active Population through Active Case Year District Region Case Search Target Population Duration Examined Coverage Search Nov-18 Ashanti Akim North Ashanti Door-to-door 79551 10 days 5092 6.40% 0 Nov-18 Akwapim North Eastern Door-to-door 165271 10 days 102236 61.86% 4 Nov-18 Akwapim South Eastern Door-to-door 44492 10 days 41076 92.32% 1 Nov-18 Asikuma-Odoben-Brakwa Central Door-to-door 150000 10 days 88399 58.93% 0 Nov-18 Ayensuano Eastern Door-to-door 92156 10 days 64987 70.52% 29.05 new 2 Nov-18 Biakoye Volta Door-to-door 80294 10 days 38966 48.53% cases per 0 Nov-18 Jasikan Volta Door-to-door 71338 10 days 39125 54.84% million 1 Nov-18 Mpohor Western Door-to-door 64075 10 days 54421 84.93% 1 Nov-18 Nkoranza South Brong-Ahafo Door-to-door 114244 10 days 59407 52.00% individuals 4 Nov-18 Sekyere Afram Plains Ashanti Door-to-door 34203 10 days 6725 19.66% examined 0 Nov-18 Upper Denkyira East Central Door-to-door 86696 10 days 41840 48.26% 0 Nov-18 Upper Denkyira West Central Door-to-door 79734 10 days 17306 21.70% 1 Nov-18 Upper West Akim Eastern Door-to-door 104885 10 days 47198 45.00% 2 Nov-18 Wassa Amenfi East Western Door-to-door 105833 10 days 12672 11.97% 0 Nov-18 Wa Municipal Upper West Door-to-door 126609 10 days 34672 27.39% 3 654,122.00 19

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Supplementary Active Case Searches (2019)

Description No. of cases confirmed of Active Population through Active Case Year District Region Case Search Target Population Duration Examined Coverage Search Dec-19 Ashanti Akim North Ashanti Door-to-door 51179 20 days 38304 74.84% 0 Dec-19 Akwapim North Eastern Door-to-door 19116 20 days 12040 62.98% 1 Dec-19 Akwapim South Eastern Door-to-door 6088 5 days 849 13.95% 2 Dec-19 Asikuma-Odoben-Brakwa Central Door-to-door 69872 15 days 62318 89.19% 44.92 new 1 Dec-19 Ayensuano Eastern Door-to-door 92156 10 days 26114 28.34% 1 Dec-19 Biakoye Volta Door-to-door 39154 15 days 34740 88.73% cases per 1 Dec-19 Jasikan Volta Door-to-door 23667 10 days 5190 21.93% million 2 Dec-19 Mpohor Western Door-to-door 9654 5 days 9134 94.61% 0 Dec-19 Nkoranza South Brong-Ahafo Door-to-door 29080 12 days 22782 78.34% individuals 1 Dec-19 Sekyere Afram Plains Ashanti Door-to-door 34563 20 days 27810 80.46% examined 0 Dec-19 Upper Denkyira East Central Door-to-door 54744 12 days 35095 64.11% 1 Dec-19 Upper Denkyira West Central Door-to-door 64457 20 days 51463 79.84% 0 Dec-19 Upper West Akim Eastern Door-to-door 57651 20 days 52602 91.24% 0 Dec-19 Wassa Amenfi East Western Door-to-door 50861 20 days 12664 24.90% 1 Dec-19 Wa Municipal Upper West Door-to-door 126609 20 days 98679 77.94% 11 489,784.79 22

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 General Observations

 Contact tracing yield increases as the numbers listed/examined increases

 Much of the contact tracing is being carrying out by focal persons/coordinators below regional level, with little involvement of other general staff  Training implications.

 Yield per capita (new case) is far greater with contact tracing than population level active case searches;

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 Conclusions

 So much is already being done within the integrated system, even without dedicated funding/budget line.

 The public health interventions surrounding Covid-19 has afforded the opportunity to train several and different cadre of staff on techniques of contact tracing;  Platform upon which we can build on

 GPZL engagement and support and eventual planned roll-out of SDR prophylaxis to contact – will stimulate the further strengthening of contact tracing.

Global consultation with NLP managers, partners and affected persons on Global Leprosy Africa, Europe, Americas; Strategy 2021‒2030 26-29 October 2020 21

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