Workshop 12: elimination of leprosy
| Chair: | S. K. Noordeen |
| Rapporteur: | Robert R. Jacobson |
Participants
| J. E. Abella | G. O. Penna |
| J. M. Flavier | C. K. Rao |
| S. O. Gokhale | P. Sommerfeld |
| M. F. Lechat | Y. Yuasa |
The success of the multidrug therapy (MDT) regimens for the treatment of leprosy developed by a World Health Organization (WHO) Study Group in 1981 prompted the World Health Assembly to pass a resolution in 1991 on the elimination of leprosy. Through this resolution WHO declared its commitment for continuing to promote the use of all control measures, including MDT together with case-finding, in order to attain the global elimination of leprosy as a public health problem by the year 2000. Elimination is defined as the reduction of prevalence to a level below 1 case per 10,000 population. In 1990, the International Federation of Anti-Leprosy Associations (ILEP) had adopted the target of MDT for all by the year 2000.
Achieving this goal through improved control efforts and provision of MDT for all leprosy cases does not mean complete eradication of the disease. It must, however, be considered the first essential step toward eventual eradication. It will lead to a situation where the disease is no longer a public health problem, i.e.. where transmission of infection is expected to be drastically reduced.
New cases will still occur, since the fall in incidence to be expected if transmission has been interrupted may lag many years behind the fall in prevalence, and this fall depends on the early introduction of MDT with sustained high coverage. This, consequently, also will lead to the reduced occurrence of disabilities.
Since the elimination strategy was adopted, progress with the widespread implementation of MDT has continued. By mid1993, over 4.1 million patients had been cured with relapse rates less than 1% overall. Likewise, the global current and cumulative MDT coverage of registered patients has reached 48% and 82%, respectively, with the number of registered cases reduced from 5.4 million in 1985 to 2.3 million now. Thus, the goal is achievable and presents a unique opportunity in the history of this disease. Its achievement, however, will require a continued major effort on the part of the endemic countries, WHO, and nongovernmental organizations (NGOs) in order to increase MDT coverage as rapidly as possible.
Strategy. The first priority must be to rapidly treat all registered cases with MDT and improve case-finding in terms of coverage and early detection. Strong political commitment and collaboration between national governments, WHO, and national and international NGOs and other donor agencies needs further strengthening to ensure the availability of the necessary resources. National plans of action are a must and will guide activities. Resources must be mobilized to assure, among other things, adequate long-term supplies of drugs and equipment. Appropriate organization of the existing leprosy services, whether vertical or integrated, and updating of existing information by clearing the registries to accurately identify the number of cases needing MDT will then allow proper implementation of the plan.
The elimination strategy aims to stratify the situation at different levels, identify priority areas for action, set intermediate targets and monitor them. Such an approach, however, should not neglect areas of low prevalence within countries or countries with a low prevalence. This requires review of the situation country by country and, within each country, area by area.
Improved case detection is important to the success of the program. Self-reporting of suspect lesions is the most cost-effective approach. Training of peripheral health services to recognize the disease is also vital. Self reporting can be encouraged through the use of volunteers and community workers and through innovative use of the media to increase community awareness of the problem and reduce the stigma.
Regular monitoring and evaluation of the program is essential to sec that progress continues toward specific targets, and that problems are identified early. Health systems research may be helpful to identify and solve problems early.
In spite of the widespread implementation of MDT and its contribution to the prevention of disabilities, there will remain a significant number of persons cither with or at risk of disability who will require care and rehabilitation.
Constraints. Bringing MDT to the remaining patients still poses a considerable challenge. In existing programs an effective infrastructure will need to be maintained, but seeing fewer patients. This would mean increasing the cost per patient. Furthermore, many patients will be in areas that are operationally difficult due to geography, infrastructure or civil disturbance.
As prevalence decreases, increased efforts to maintain the political commitment for the program will be necessary because the needs of leprosy control may be considered in relation to the needs of other health problems and health policy in general. Program planning now must look beyond attainment of the elimination to the maintenance of the necessary skills to detect cases where the prevalence becomes very low. This may be accomplished by training personnel to suspect leprosy whenever appropriate and by the maintenance of a core area of expertise to confirm the diagnosis of cases on referral and to manage complicated cases. In this and in the urban control efforts, the private medical sector may play a significant role in certain countries provided they follow the national guidelines regarding classification and therapy.
Existing cases requiring MDT and cases expected to be detected between now the year 2000 may total as many as 6 to 7 million patients. It is estimated that US$400-$500 million will be required for this effort. Thus, the continued commitment of national governments, NGOs and WHO until the year 2000 and beyond is vital if this effort is to succeed.
Research. Current research efforts may yield shorter-term therapy and/or fully supervisable therapy for those cases who require other than standard MDT. These would accelerate the attainment of the elimination goal. Other areas of research should include improved antireaction therapy and prevention of nerve damage.
Conclusions. Intense efforts on the part of all involved are required to eliminate leprosy as a public health problem by the year 2000. The basic resources and technology exist. It would be inexcusable if the efforts are not made and this historical opportunity was missed.