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  • Volume 69(2 Suppl 1) , Number 2
  • Page: 7–9
STATE-OF-THE-ART LECTURES

The final push to eliminate leprosy

Maria P. Neira






ASIAN LEPROSY CONGRESS

This Congress, the first in the new millennium and one held at a time when there are both opportunities and challenges ahead of us, is of great importance. As we approach a turning point for making real changes to control leprosy in a sustainable manner, I should like to share with you what we are trying to do and what our remaining challenges are today.

Leprosy is one of the few infectious diseases that meet the especially demanding criteria for elimination: practical and simple diagnostic tools, availability of an effective intervention to reduce its transmission, and a single reservoir of infections- humans.

Eliminating leprosy has far greater implications than simply resolving a public health problem. Leprosy is closely linked with poverty and its elimination will contribute to poverty alleviation. Poverty is both a cause and a result of leprosy. A "cause" because poor people are more prone to suffering from the disease, owing to their weaker immune systems and the higher transmission rates created by living in such close proximity to each other. A "result" because it is one of the leading causes of permanent disability with the chronic symptoms often afflicting individuals at the most productive stage of their lives, preventing them from generating income. In this way they are forced to impose significant economic and social burdens on their families.

By strengthening our leprosy control program we can make a final push to eliminate leprosy and, thus, a direct attack on one of the major causes of poverty. Leprosy is also a prime example of the link between ill-health and the lack of sustainable development. Eliminating it will have a dramatic impact on the overall economic empowerment of the millions affected by it.

The large-scale use of effective strategies such as multidrug therapy (known as MDT) has raised the prospect of seeing an end to a disease that has been with us since time immemorial and that has afflicted unnecessary suffering on many.

So where do we stand? A resolution to eliminate leprosy as a public health problem was endorsed by the World Health Assembly in 1991. Elimination was defined by WHO as a prevalence rate of less than I case per 10,000 population. A great deal has been achieved so far. More than 10 million people have been cured of leprosy, and the global prevalence rate has dropped by 87% to reach 1.3 per 10.000. At the beginning of the year 2000. there were 750.000 registered cases in the world, and during 1999 alone about 740,000 new cases were detected. The alleviation of human pain and suffering brought about by this progress is immeasurable.

But we still have a long way to go. The prevalence of leprosy is still over four times the target level in the 10 most affected countries. These countries represent approximately 90% of the global leprosy burden. The reasons for these countries missing the deadline are varied and include: the high prevalence itself, the intensity of disease transmission, and limited geographical coverage with MDT services. In a few countries experiencing civil strife, elimination efforts are seriously undermined by a damaged health infrastructure.

Most importantly, there is still a substantial hidden caseload, as suggested by thehigh numbers of new cases emerging with the widening coverage of leprosy elimination campaigns. The reasons for these hidden cases are complex. People in rural areas have poor access to diagnosis and treatment because of the limited coverage of leprosy services. These are often only available through specialized clinics set up especially for leprosy for a few hours a month, and not through the general health services on a daily basis. Because leprosy is usually handled by specialized teams, there is limited awareness of the early signs of leprosy- not only among the general public but also among health care providers. The stigma surrounding leprosy also creates a tremendous psychological barrier for patients to seek timely treatment.

What is being done to address these problems? For the first time ever the "leprosy world" has formed a Global Alliance with all the key partners adopting a common strategy and resolving to intensify its implementation. In addition to WHO, core members of the Alliance are health authorities from the top most endemic countries, The Nippon Foundation. Novartis, the International Federation of Anti-Leprosy Associations (ILEP), together with, in India, the World Bank and DANIDA. WHO acts as secretariat and coordinates all activities.

In this final phase our efforts will focus on empowering communities and health services to deal with leprosy, transferring to them the ownership of leprosy elimination. Speaking in concrete terms, this means integrating leprosy services within the general health services, changing the pervasive negative image surrounding the disease, and raising awareness in communities that leprosy can be cured. It will involve:

  • Improving access to leprosy services by enabling all health facilities in endemic districts to diagnose and treat leprosy. Leprosy can be diagnosed on clinical signs alone and, after minimal training, general health workers are capable of diagnosing and treating leprosy.
  • Ensuring availability of free MDT drugs at health centers through improved distribution and logistics
  • Encouraging people to seek timely treatment by creating better community awareness of the early signs of leprosy and dispelling any fear of the disease, which generates such irrational prejudice and stigma. People often delay seeking treatment owing to fear of its social consequences which, in some societies, is extremely grave.
  • Ensuring high cure rates through innovative and patient-friendly drug delivery systems. Many patients have to interrupt their treatment owing to lack of drugs or because the health services are inaccessible owing to weather conditions, poor roads or social reasons. Innovative solutions in line with local realities will help overcome such obstacles.
  • Active monitoring to keep track of progress toward elimination and taking timely corrective action to tackle the remaining problems

Decisive implementation is the key to our success. We could spend months or even years refining our strategy in meetings but that will not bring us any closer to our goal. In order to accelerate and standardize the implementation of this strategy, "elimination kits" have been developed and are being actively implemented by endemic countries. These kits comprise templates, texts and visual aids that will be adapted to local contexts and will address four key pillars of the strategy:

  • Capacity building to enable general health care staff to diagnose and treat leprosy as well as its complications
  • MDT and logistics to ensure that adequate stocks of MDT are available at the peripheral level
  • Information and advocacy to encourage people to seek treatment and creating a positive image for leprosy elimination in communities
  • Monitoring systems to keep track of new caseloads, cure rates and progress towards elimination

We- and by "we," I mean the Alliance- continue to focus our efforts on areas with the greatest problems. Priorities have been set on current prevalence rates, resulting in countries being grouped into one of three categories: intensification, acceleration and consolidation. Priority will clearly be given to the countries in the intensification group.

In this regard, India is at the front line of the fight against leprosy. For almost 45 years, India relied on a centrally sponsored vertical leprosy control program. This program has helped in making tremendous progress. However, this approach is no longer cost-effective, and national authorities have decided to take the bold step of making historical changes. The two key elements are: a) to give ownership to the states and districts so that elimination activities will be adapted to the local reality, and b) to integrate MDT services within the vast primary health care structure. These major institutional changes will need intensive planning, implementation and close monitoring.

Why integration is essential. Integration of leprosy into the general health services is an integral element of the WHO strategy in the final push to eliminate leprosy. This is considered to be the most effective method of ensuring that the significant progress that has been made so far in leprosy elimination is sustained. Once the general health services assume responsibility for diagnosis and treatment of leprosy, the access of patients to these essential services will improve. Moreover, future cases will be sure to receive timely and correct treatment. Cases will inevitably appear even after elimination has been achieved because of the long incubation period of the disease. However, integration will help remove the "special" status that leprosy suffers from and which, in the eyes of health workers is a complicated disease that has to be handled by specialized staff, in the eyes of patients is a special disease that needs to be treated by special people, and in the eyes of the community is a special disease that is different from others.

Integration will also render the program more cost-effective and sustainable with national resources- without foreign funding or borrowing- and thereby ensure the long-term sustainability of leprosy elimination.

Who does what within the Alliance? The roles of the partners are distinct and complementary. National health ministries will continue to play the key role in eliminating leprosy and will implement the strategy and monitor progress. The commitment and leadership remain crucial.

WHO will continue to provide technical and strategic leadership to the elimination program as well as deal with MDT logistics. It will further intensify its efforts to guide and monitor field-level operations to ensure effective implementation.

The Nippon Foundation and the Sasa-kawa Memorial Health Foundation will contribute US$24 million to WHO to support country-level activities.

Novartis will donate MDT to WHO over the next 6 years, to the approximate value of US$30 million, in order that all leprosy patients throughout the world can receive treatment free-of-charge.

ILEP, with its long tradition of active engagement in field programs, will maintain its participation in wide-ranging activities through their extensive network in the field.

The Alliance will also work closely with patients, communities, national governments and all agencies interested in leprosy such as Danish International Development Assistance (DANDIDA) and the World Bank.

What are the benchmarks? This year, most of the groundwork has been completed. This includes setting up the national tasks forces, developing plans based on local situation analyses, and developing and adapting generic elimination kits.

All of the elements necessary to eliminate leprosy are now in place: the strategy, the tools, the resources, the know-how and the drive to make it happen- providing a unique historical opportunity to succeed.

By the end of 2003, leprosy will have been integrated into the general health services leading to the detection and cure of an additional approximately 2.5 million cases. Leprosy will y then be eliminated in almost all countries.

By the end of 2005, leprosy will have been eliminated at the national level in all countries and, ideally, at the subnational level, too. Moreover, at such time, the elimination of leprosy will be validated.

I am confident that this Congress will be very productive and successful. Let's all be as innovative as possible so that the next time we meet it will be to celebrate the elimination of leprosy.

 

 

 

 

 

 

 

 

 

 

Director; Department of Control, Prevention and Eradication World Health Organization Geneva, Switzerland.

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