Overcoming the last mile: practical strategies for leprosy elimination in Pakistan.

Leprosy, a neglected tropical disease (NTD) caused by Mycobacterium leprae, continues to affect vulnerable populations in low-endemic countries like Pakistan despite its official elimination as a public health problem in 1996. With 236 new cases reported in 2023, including 16 among children, ongoing transmission highlights significant gaps in Pakistan's leprosy elimination strategy. This paper explores key challenges, including diagnostic delays, limited retrospective contact tracing and resource constraints, which hinder progress towards Zero Leprosy. Drawing on decades of field experience from Pakistan's specialised leprosy services, including the Marie Adelaide Leprosy Centre and Aid to Leprosy Patients, we propose practical, evidence-informed strategies to overcome these barriers. These include scaling up active case finding initiatives, implementing single-dose rifampicin as post-exposure prophylaxis, leveraging Geographic Information System technology for hotspot identification and integrating leprosy services with other skin-related NTDs. Additionally, we emphasise the importance of strengthening non-governmental organisation collaboration and broader multistakeholder partnerships, enhancing healthcare worker training and addressing social stigma through community engagement. By presenting actionable lessons from Pakistan, this perspective aims to inform global efforts to eliminate leprosy and other NTDs, particularly in similar low-endemic settings. Achieving Zero Leprosy requires sustained political commitment, increased resource allocation and a multifaceted approach that addresses both medical and social dimensions of the disease.