LEPROSY - W.H.O.'s COUNTDOWN TO ELIMINATION
"PROGRESS TOWARDS LEPROSY ELIMINATION:-
Significant advances have been made towards the goal of eliminating leprosy as a public health problem. In most of the endemic countries, an increasing number of patients have better access to multi-drug therapy (MDT). Coordinated and intensive efforts on the part of governments, the scientific community, international and national NGO's have greatly contributed to simplifying the existing technology and making it available even under difficult conditions. However, as we approach the target date for elimination, new issues and challenges are arising. As might be expected, it is becoming increasingly difficult to conquer the disease in places where its prevalence is high and access to health services is limited. On the other hand, national elimination programs, together with their partners, are responding remarkably well to these challenges by identifying difficult situations and rapidly implementing innovative solutions. The 7th. W.H.O. Expert Committee on Leprosy, which met in Geneva in June 1997, underlined the value of such interventions: "There is an important need to detect and treat the remaining undetected cases, for which special approaches, along with extension of multi-drug therapy (MDT) services to all general health facilities, are required. The progressive simplification of diagnostic and treatment technologies has continued to facilitate reaching more leprosy patients."
The extent to which the global strategy for eliminating leprosy has succeeded in reducing, if not interrupting, transmission of the disease, is the subject of much debate at the moment, and measuring this represents a considerable challenge to epidemiologists. Unfortunately, reliable tools for measuring leprosy infection are still not available; for the time being, the only possibility of monitoring progress towards leprosy elimination is to ensure that complete coverage with MDT services is achieved and sustained. Over the last two years, W.H.O. has been promoting initiatives aimed at increasing this coverage through elimination campaigns, further integration of elimination activities within general health services and uninterrupted supplies of MDT drugs, free of cost to patients. As a result, the detection of leprosy has significantly increased in almost all endemic countries and it is expected to continue to increase during the next year. Although this approach poses problems in interpretation of data apart from technical and operational problems , it is essential that elimination be based on reliable evidence and not just reflect the absence or weaknesses of leprosy services or of information systems. This report records the progress that has been made towards the goal of elimination of leprosy as a public health problem, and updates figures published in June 1997.
GLOBAL AND REGIONAL LEPROSY SITUATION ( Countries endemic for leprosy)
As of the end of 1997, leprosy was still considered a public health problem in 32 countries (population above one million and prevalence rate above 1 case per 10,000 population), situated mainly in the intertropical belt of the world. Most of the global leprosy burden is now concentrated in 16 countries from the Asian, African and American continents. Moreover, it appears that the disease is now shrinking to limited geographical areas within endemic countries where it becomes possible to isolate pockets of high levels of endemicity. This phenomenon can be explained by both operational and epidemiological factors, and is best described through Geographical Information Systems. Most of the endemic countries have now implemented district level databases which permit more detailed analysis and more closely targeted interventions.
At the beginning of 1998, a total of 828,803 cases were registered as under treatment globally. Distribution of registered prevalence by W.H.O. Regions indicated various levels of endemicity in the world, as follows :- Africa - 82,522; Americas - 119,279; S.E.Asia - 591,069; Eastern Mediterranean - 11,977; Western Pacific - 23,413; Europe - 543. This means that the number of cases per 10,000 in the following areas is :- Africa 1.29; Americas - 1.48; S.E. Asia 3.99; Eastern Mediterranean - 0.24; Western Pacific - 0.14; Europe - 0.01 . A more detailed epidemiological report may be obtained by accessing the W.H.O. web-site via "FORUM ON LEPROSY", by going to the bottom of that page and clicking on "other links - WHO/LEP."
About 642,000 cases were detected during 1997 as notified by 104 countries. Some endemic countries (Brazil, Congo, Cote d'Ivoire and Gabon) were not able to send information at the time of preparation of this report. Assuming that these countries would have detected the same number of patients during 1997 as during 1996, we can estimate the global detection to be as high as 685,000 (a detection rate of 11.5% per 100,000 population) . About 652,500 cases (95%) were detected in the 16 major endemic countries, and 76% of the newly detected cases are living in India alone. Detection trends in the most endemic countries will be presented and analysed in the next report for the Weekly Epidemiological Record.
Among newly detected cases for which detailed information was provided, 10.3% are children below 15 years of age and 42% are multibacilliary (MB) patients. About 11% showed severe disabilities at the time of diagnosis
The profile of newly detected cases with regard to MB proportion and skin-smear status in selected countries of high endemicity shows India with 519,952 new cases of which 200,374 were detected as MB, being 38.5%, skin-smear positive cases 7%, and new cases with bacteriological index>3+%. Brazil comes second with 39,792 new cases of which 17,000 were MB, being 42.7% and 17.7% showing skin-smear positive. New cases with bacteriological index>3+% is 4.5. For further details, please e-mail - email@example.com - or access W.H.O. statistics via the "Forum on Leprosy". Based on information from 10 countries, it is estimated that 60,000 (9%) of newly detected cases in 1997 would have a positive skin-smear.
PROGRESS WITH MULTI-DRUG-THERAPY (MDT) COVERAGE:-
Almost all leprosy patients registered for treatment are now being treated with MDT, even in counties facing difficult practical problems. During 1997, the total number of patients treated with MDT exceeded 1.5 million (old and new patients).
With the large experience gained in using MDT, even under difficult conditions, the WHO Expert Committee on leprosy has recommended simplified procedures aimed at making access to MDT easy for all patients. As countries approach the elimination target, program managers are increasingly concerned with the numbers of patients defaulting on treatment, and of relapses, as potential sources of re-emerging transmission of the disease, including the risk of resistance to existing antibiotics. While the cumulative number of defaulters and relapses is significant, rates are relatively low and these patients do not represent a major risk of becoming a hidden source of infection. Happily, no case of MDT drug resistance has been reported so far with standard WHO treatment with MDT. Concerns have been raised about the possible threat of a very high proportion of patients presenting late relapses (more than seven years after being cured) but this has not yet been observed on any appreciable scale.
DETAILED SITUATION IN THE TOP 16 ENDEMIC COUNTRIES.
Leprosy remains a public health problem in 32 countries, but 16 countries contribute to 92% of the leprosy problem in the world, viz:- India, Brazil, Indonesia, Bangladesh, Nigeria,Myanmar, Mozambique, Democratic Republic of the Congo, Nepal, Ethiopia, Madagascar, Sudan, Philippines, Guinea, Niger and Cambodia.
The global strategy and plan of action for eliminating leprosy as a public health problem (that is, reducing the prevalence of the disease to below one case per 10,000 population at global and national levels) has been so successful that it is now possible to envisage eliminating the disease at sub-national levels and thus bringing about a further reduction in transmission. In all countries where leprosy is still occurring, this target should result in stopping the disease and its social, physical, cultural and economical consequences. Based on simplified approaches to case-finding at community level, MDT treatment and epidemiological surveillance, the global elimination strategy has proved to be one of the most cost-effective interventions in the public health domain
It is now essential for countries where leprosy still occurs, to identify districts or pockets where the prevalence continues to be high and where the community is at higher risk of being infected with M.leprae. Based on this, such countries should : promote extensive community awareness campaigns at the most peripheral levels; continue to apply simplified diagnosis and treatment with MDT in order to facilitate the integration of leprosy elimination activities into general health services; promote the prevention of disabilities (POD), particularly during treatment; and maintain strict epidemiological surveillance."
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