INTERNATIONAL. JOURNAL. OF LEPROSY^ Volume 65, Number 4

Printed in the U.S.A.(ISSN 0148-916X)

A Practical Method of Active Case Finding andEpidemiological Assessment: Its Origin and

Application in the Leprosy Control Project in Indonesia'Andy A. Louhenapessy and Bos Zuiderhoek 2

HISTORICAL BACKGROUNDA method of active case finding, called

the propaganda treatment survey (PTS) sys-tem, was introduced by Muir and Rogers inIndia in 1927. The basic idea was to detect,by means of health education, and to bringunder treatment as many leprosy patients aspossible at an early stage of the disease.

More or less the same system wasadopted by Sitanala (The Figure) for In-donesia in 1932 ( 2 . 8 ). It was introduced un-der the name of exploration surveys, andthe main aim was to gain an idea of the lep-rosy situation in areas in which the diseaseseemed to be highly prevalent. At the sametime, these areas were used for epidemio-logical research and treatment trials.

The way the surveys were carried out isof special interest and is described in detailby Tumbelaka ( 5). Health education wasgiven to all authorities concerned duringtheir weekly meetings. Hygiene, clinicalsigns of leprosy and the policy of controlwere discussed. The latter was based on apreliminary study of the beliefs of the localpopulation with regard to leprosy.

With the assistance of the local authori-ties, potential patients were traced, exam-ined and their contacts checked. Chaulmoo-gra oil and its derivatives were the medi-cines of choice. Patients were advised tolive separately from their families but in thesame compound and to keep themselvesbusy. This was known as the Norwegian

' Received for publication on 30 April 1997. Ac-cepted for publication in revised form on 10 Septem-ber 1997.

= A. A. Louhenapessy, M.D., M.P.H., Chief, Divi-sion of Leprosy Control, Department of Health, Gov-ernment of the Republic of Indonesia, 1974-1984. B.Zuiderhoek, M.D, WHO Consultant for Leprosy to In-donesia, 1974-1986.

Reprint requests to: B. Zuiderhoek, Fideliolaan 102,1183 PP Amstelveen, The Netherlands.

system ( 2 ' 5). Accidental diseases weretreated and hygiene improved.

The result of this humane approach wasthat more and more patients came forwardvoluntarily after the surveys had finished.The method was discussed at the Interna-tional Leprosy Congress in Cairo in 1938,whereupon a Committee of the League ofNations visited Java to study the procedure.

OLD METHOD USED AFRESHThe principle of exploration surveys was

re-introduced in Indonesia in 1977, first ofall in the eastern province of South Su-lawesi. At that time, local random samplesurveys revealed an estimated prevalence ofup to 15.3 per 1000 (±3.4 95% confidencelimits) against a registered one of around 3per 1000. Health centers and subcenterswere found all over the province. All med-ical personnel were trained in leprosy con-trol and the treatment available. Contactsurveys and school surveys were routinelycarried out and health education given.Why did a considerable number of patientsstill escape our attention?

A pilot project, based on the principle ofcase finding in an exploration survey wascarried out in a subregency called Bantimu-rung. In a population of 40,000, 48 indeter-minate/tuberculoid (I/T) and no less than 62borderline/lepromatous (B/L) cases (Ma-drid classification) were newly detected. Aninterview by a health educator revealed thatthe majority of these patients were eager tobe treated but shy about visiting the HealthCenter and preferred to take the drug fromnearby local authorities. Moreover, familymembers prevented them from showingthemselves in public since they were afraidof being identified with the disease.

It became clear that health education forthe patient, family and the public should be

487

488^ International Journal of Leprosy^ 1997

THE FIGURE. Dr. J. B. Sitanala.

increased and that the problem could not besolved without the active participation ofthe community. Local authorities provedable to overcome the stigma in their deal-ings with the patients and their families.

In view of the result of this pilot survey,the government decided to reintroduce theprinciple of the old exploration surveys inIndonesia and to start in the province ofSouth Sulawesi where the disease washighly endemic. The surveys were giventhe name of chase or trace surveys ( 4).

At that time South Sulawesi consisted of21 regencies, divided into 155 subregen-cies, each with an average population of32,000. Chase surveys were carried out ineach subregency. An experienced leprosyworker addressed all local civil authorities,religious leaders and members of the socialcommittee at their regular meeting, focus-ing attention on the signs of leprosy and theefficacy of treatment, especially at an earlystage. They were informed that leprosycould be cured and that treatment was freeof charge. Ample time was reserved forposing questions.

Cooperation was requested for the pur-pose of contacting, by subtle means, per-sons suspected of having leprosy; emphasiswas placed on the need for examinationand, in cases of persons shown to have lep-rosy, treatment. High priority was to begiven to health education all over the area.Lists with names were collected by the lo-cal medical officer after 1 month. Personson the lists and their contacts were exam-ined at home or at the Health Center. Thiswas followed by treatment, if necessary. Pa-tients already registered were checkedagain. Information from patients resulted inthe detection of more cases. Ever since,these surveys have been carried out accord-ing to the same guidelines.

As mentioned before, random samplesurveys revealed the existence of a consid-erable number of undetected cases and,therefore, the aim of the chase surveys wascase detection. Every regency had its ownteam of leprosy workers, and each team hadto cover a different number of subregencies,depending on the size of the population.The average time needed to cover one sub-regency was about 3 months, and the sur-veys were carried out one at a time as partof the leprosy workers' routine duties.

RESULTSDuring the chase surveys in the 155 sub-

regencies of South Sulawesi, in a popula-tion of 4,960,000 a total number of 6280cases were newly detected, namely, 3865I/T and no less than 2415 B/L cases, all inneed of treatment and nearly all with a casehistory of more—and in some cases muchmore—than 1 year. It is fair to assume thatmany would never have sought treatmentvoluntarily, although a number of I/T casesmight have healed spontaneously.

It is worthwhile to look in more detail atthe chase surveys in the Bone Regency.Leprosy is highly endemic in this regencywhich, with 21 subregencies, is the biggestin South Sulawesi. Here, the local leprosyteam had been reinforced by two experi-enced nurses from The Leprosy Mission.During the period 1983-1987 all subregen-cies were covered by chase surveys, and ina population of 643,000 a total of 1492cases (852 I/T and 640 B/L) were newly de-tected, mostly with a case history of morethan I year. All needed treatment. Twenty-

65, 4^Louhenapessy and Zuider/zoek: Practical Active Case Finding^489

five percent came within disability gradeII/III (WHO classification 1970).

It should be mentioned that, by othermeans of detection, 1166 patients (448 I/Tand 718 B/L) came forward during thesame period. This means that 66% of theI/T and 47% of the B/L cases were discov-ered in the chase surveys. However, thesepercentages have to be treated with somecaution since some cases, detected in chasesurveys, might have come forward in othercase-finding activities had they not beenpreviously caught in chase surveys.

Immediately after finishing the chasesurveys, a random sample survey in this re-gency revealed an average estimated rate ofstill-undetected paucibacillary (PB) andmultibacillary (MB) cases (WHO classifi-cation 1988) of 6.7 and 0.2 per 1000, re-spectively. It seemed that the majority ofMB cases had been detected, but that therewas still a considerable reservoir of unde-tected PB cases, 60% of them with a casehistory of more than 1 year. Although epi-demiologically of limited importance, theyrepresented a potential cause of disability.Nevertheless, disabilities grade II/III werenot (yet) found among these newly detectedpatients in the sample.

DISCUSSIONIt is clear that chase surveys have proved

their usefulness in Indonesia. Local author-ities were able to overcome the stigma andto convince patients to go for examinationand treatment. Without this "push" manywould never have sought treatment volun-tarily. A pre-condition for the surveys wasthat sufficient medicine could be assuredfor the whole period of treatment of allnewly detected cases.

In addition to the conventional methodsof active case finding, chase surveys arevery effective in high-endemic regions, es-pecially in the initial phase after openingnew project areas, but they can also be usedfor this purpose in low-endemic regions. Ifincluded in the leprosy workers' routine du-ties, no additional expenses are incurred.Afterward, repeated contact with the localauthorities is recommended to ensure thatno recognizable cases escape our attention(mini-chase surveys).

At the same time, chase surveys providegeneral information about the local leprosy

situation. If necessary, they can be carriedout for this purpose on a random sample ba-sis. This principle, known as the rapid vil-lage survey, has been recommended in re-cent publications ( 1 ' 3 ' 7 ).

Chase surveys provide no more than anapproximate reflection of the real situation.They are not an alternative to random sam-ple surveys in high-endemic regions. Be-sides providing a wealth of additional infor-mation, random surveys reflect the truerates of undetected cases. How many pa-tients are still hiding? What is their classifi-cation and age? What is their disability rateand case history? This is important infor-mation required to detect unknown sourcesof infection.

In the low-endemic areas of Indonesia,random sample surveys were not recom-mended unless political or other importantreasons required a more detailed picture ofthe situation. Here, chase surveys or mini-chase surveys can play a prominent role (').

Considering the results of the chase sur-veys in Indonesia, one very much wonderswhether elimination of leprosy can beachieved without emphasizing the impor-tance of active case finding, especially inareas in which the disease is still highly en-demic. In 1977 active case finding was stillhighly recommended (a); nowadays, theelimination program is based mainly onpassive case finding, and active case findingdealt with in a neglectful fashion. One canpostulate that the results of niultidrug ther-apy (MDT) would encourage new patientsto go voluntarily to clinics to get their med-ication but during the chase survey in BoneRegency all known patients were alreadyreceiving MDT. Nevertheless, it appearedthat many still needed a "push" to comeforward.

SUMMARYRandom sample surveys in the past have

revealed high estimated against low regis-tered prevalences for leprosy in severalparts of Indonesia. A pilot project showedthat the problem of cases that had not yetbeen detected could not be solved withoutthe active participation of the local authori-ties, who proved able to overcome thestigma and to convince potential patients togo for examination and treatment. The pilotproject was based on the principle of what

490^ International Journal of Leprosy^ 1997

are called exploration surveys, which wereintroduced by Sitanala in Indonesia in1931. The Indonesian government decidedto reintroduce these surveys in 1977 underthe name of chase or trace surveys. Theyare carried out within the framework of theleprosy workers' routine duties and no ad-ditional expenses are incurred. Since then,thousands of patients of all types and withlong case histories have been detected andbrought under treatment. Without this"push" it is fair to assume that many wouldnever have sought treatment voluntarily. Inview of the experience in Indonesia, onewonders whether leprosy can be eliminatedwithout emphasizing the importance of ac-tive case finding, especially in areas inwhich the disease is still highly endemic.Chase surveys also provide rough informa-tion about the local leprosy situation. Al-though of great value, they are not, in high-endemic regions, an alternative to randomsample surveys which reveal, besides awealth of additional information, the possi-ble unknown sources of infection.

RESUMENEn indonesia, los programs de exploraciOn al azar

aplicados en el pasado, consistentemente retlejabantasas bajas de prevalencia de Ia lepra. Un proyecto pi-loto mostr6 que el problem de los casos no detectadosno podria ser resuelto sin la participaciOn activa de lasautoridades locales quienes demostraron su capacidadpara minimizar cl estigma de la enfermedad y paraconvcnccr a los pacientes potenciales de asistir a exa-men medico y de someterse a tratamiento. El proyectopiloto estuvo basado en las Ilamadas jornadas de ex-ploraciOn introducidas por Sitanala en 1931. El go-bierno de Indonesia decidiO reintroducir este programaen 1977 bajo el nombre de jornadas de caza para la de-tecciOn de casos. Estas jornadas se efectdan dentro delmarco de las actividades rutinarias de los trabajadoresde la lepra, sin Ia necesidad de incurrir en gastos adi-cionales. Desde entonces, cientos de pacientes de todotipo, incluyendo casos de larga duraciOn, se han detec-tado y se han puesto bajo tratamiento. Sin este "empu-jon" es seguro que muchos de los casos nunca hu-bicran solicitado tratamicnto de manera voluntaria. Envista de la expericncia en Indonesia es dificil aceptarque la lepra pucda ser erradicada sin recurrir a labtisqueda activa de los casos, especialmente en aquel-las areas donde la enfermedad es de alta endemia. Lasjornadas de caceria de casos tambien proporcionan in-formaciOn sobre la situaciOn local de la lepra. Sin em-bargo, aunque estas jornadas de caceria resultan degran valor en las regiones de alta endemia, no substi-tuyen a los estudios de exploraciOn al azar ya que es-

tos, ademas de proporcionar una buena cantidad de in-formaciOn adicional, rcvelan las posibles fuentes de in-fecciOn.

RÉSUMÉDes enquetes par echantillonnage aleatoire out

revele dans le passé des prevalences elevees pour lalepre dans differentes regions d' Indonesie, alors queles previdences enregistrees etaient basses. Un projetpilots a montre que le probleme des cas qui n'avaicntpas encore (le detectes nc pouvait pas etre resolu sansIa participation active des autorites locales, qui semontrerent capables de surmonter le stigma et de con-vaincre les patients potentials de rechercher l'examenet le traitemcnt. Le projet pilots etait base sur leprincipc de ce qu'on appelle des enquetes explora-toires, introduites en Indonesie par Sitanala en 1931.Lc gouvemement indonesien decida de reintroduireces enquetes en 1977 sous lc nom de "chase-surveys"ou "trace-surveys." Elles sont realisees dans le cadredes activites de routine des travaillcurs de la lepre, etn'entrainent aucune depense additionnelle. Depuislors, des milliers de patients de tons types et avec desmaladies de longue duree ont etc detectes et mis soustraitement. Sans cette "impulsion," it est raisonnablede supposer que beaucoup n'auraient jamais recherchévolontairement le traitement. Au vu de l'experience in-donesienne, on se demande si la lepre pout etre elimi-née sans insister sur l'importance de lit detection active,particulierement dans les regions dans lesquelles lamaladic est encore fortement endemique. Ces enquetesexploratoires fournisscnt egalement une informationgrossiere sur la situation locale en ce qui concerne lalepre. Bien que de grande valcur, elles ne sont pas, dansles regions a haute endemicite, une alternative aux en-quetes par echantillonnage aleatoire qui revelent, en plusdune moisson d'inforrnations additionnelles, les sourcesinconnues possibles de l'infection.

Acknowledgment. The authors are very gratefulto the government of Indonesia for permission to pub-lish this paper and for its continuous support to the lep-rosy control program. We thank the World Health Or-ganization, the Danish Save the Children Organiza-tion, and The Leprosy Mission for their constanttechnical and material help. The assistance of Dr.Bahrawi Wongsokusumo, former Director General,CDC, and Dr. M. R. Teterissa, former Chief, Divisionof Leprosy Control, is gratefully acknowledged. Spe-cial appreciation is due to Dr. Sandy Ritung, formerDirector, National Leprosy Training Centre, for hisvaluable assistance. The support of Dr. H. M. 'thinAmiruddin, former Chief, Health Services, Bone Re-gency, and Dr. Arsyad Puji, health educator, is highlyappreciated. Finally, we wish to acknowledge withgratitude the valuable contribution of all the staff ofthe Health Services and the nurses of The LeprosyMission as well as the active assistance of the authori-ties and the public.

65, 4^Louhenapessy and Zuiderhoek: Practical Active Case Finding^491

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