Dermatologists combat leprosy in Yemen

Background Leprosy has been prevalent in Yemen for many years. The ostracization and stigmatization of leprosy patients are well documented in the Yemeni literature. No control activities were carried out until 1980. Aim To document the development of leprosy control activities in the Republic of Yemen during the period from 1982 to 1996. Materials and methods The dermatologists in Yemen used various methods, including the media, to fight the stigma of leprosy and thus to mobilize the community for the reintegration of leprosy patients. They sought support from international non-governmentai organizations (NGOs) to start mobile teams all over the country. Results The support of the German Leprosy Relief Association (GLRA) and the World Health Organization (WHO) enabled the National Leprosy Control Program (NLCP) to reach people in remote areas. The prevalence of leprosy has declined from 1.9 per 10,000 population in 1989 to 0.5 per 10,000 population in 1996. Conclusions The stigma associated with leprosy also extends to other skin diseases. To combat this stigma, various methods, such as health education, training of medical personnel, and mass treatment for skin diseases, have been used.     

Trends in detection of new leprosy cases at two centres in Himachal Pradesh, India: a ten-year study

An impressive decline in leprosy prevalence rate (PR) in all endemic districts of India is seen in the post-MDT era. However, the new case-detection rate, an important statistical indicator in leprosy control programmes, has not shown significant decline in spite of all efforts. In Himachal Pradesh, a decline in PR from 7.8 to 0.56/10000 between 1991 to 2000 is seen, and recently the State has won national acclaim for having achieved the goal of elimination of leprosy in all the districts. The vertical leprosy programme has been integrated into general health services of the state. An analysis of data from 1991 to 2000 of two leprosy control units of Himachal Pradesh, the Urban Leprosy Clinic in Shimla (ULC-S) and the District Leprosy Control Unit in Mandi (DLCU-M), showed no significant decline in the new cases detected. 277 and 271 new cases were detected at these centres respectively; these included 2.2% and 1.5% children of less than 14 years of age. Almost 75% of these cases were males and of MB type. A steadily increasing trend in the annual detection of new cases was seen at both the centres during the decade. The cases registered at DLCU-M were mainly indigenous to the district. At ULC-S, 45 migrant cases from other endemic areas-mainly from Nepal, Bihar, and Uttar Pradesh-had also contributed to the increased number of new cases. Other possible causes discussed for this higher new case detection, e.g. overdiagnosis, detection of backlog "hidden cases" and voluntary reporting of patients, do not differ from those seen in other parts of the country or the world.     

Guidelines for carrying out leprosy elimination campaigns 1996. WHO, Action Programme for the Elimination of Leprosy

A Leprosy Elimination Campaign (LEC) is an initiative which aims to detect leprosy cases, particularly the more serious ones referred to as 'cases of consequence', that remain undetected in the community, and to treat them with MDT. This will subsequently reduce the delay in managing such cases in the community and ensure that the existing health services are able to treat them. It is a time-bound, one-time activity. Leprosy of consequence is defined as cases with more than five skin lesions and skin smear positive cases. Such cases are regarded as being of consequence because they act as a major source of infection in the community and are either already disabled or at high risk of becoming disabled. LEC is a focused combination of activities which includes: orientation courses for local health workers and volunteers; community awareness creation activities; case-finding and treating every detected case immediately with MDT. These campaigns are to be carried out primarily in endemic regions where the prevalence and new case detections are high and where the gap between estimated and registered cases is large. It is a national activity, implemented by the national staff with technical cooperation from WHO and other agencies.     

Recent trends in leprosy in a large district of West Bengal, India, revealed by a modified leprosy elimination campaign (MLEC), 1998

A Modified Leprosy Elimination Campaign (MLEC) in September 1998 in the District of Midnapore, West Bengal, covered a population of 8.1 million people and detected 8181 new cases. Available data from 7328 cases were studied to observe the trend for leprosy in this area. Data are presented on sex and age distribution, classification and the proportions of multibacillary (MB), paucibacillary (PB) and single skin lesion (SSL) cases discovered in a period of only 8 days. The large numbers of people examined in this district and the high total of new cases revealed are in keeping with experience in other parts of the State and in other parts of India. However, many cases were found in endemic areas and these will receive special attention in a second MLEC, planned for January 2000.     

A comparison of Rapid Village Survey and Leprosy Elimination Campaign,detection methods in two districts of East Java,Indonesia, 1997/1998 and 1999/2000

A Rapid Village Survey (RVS) was planned to estimate the extent of the leprosy problem in two well documented endemic districts of East Java, Indonesia. Furthermore, the aim was to investigate the efficacy of the routine programme in detecting new and early cases, as well as the feasibility of RVS in detecting disabled people affected by leprosy in the community. A random sample survey (RVS: a simple method compared to a Population Sample) was used to determine the extent of the leprosy problem. In addition, a Leprosy Elimination Campaign (LEC), was used particularly to detect new and backlog cases in the community. Both RVS and LEC involve a health education campaign followed by the examination of persons voluntarily reporting. Routine programme case finding, involving passive case finding and contact examinations, was also carried out. The RVS prevalence rate of 12 per 10,000 was more than twice the known prevalence rate of 5 per 10,000. The LEC prevalence rate was less than the rate found by RVS, but was within the RVS confidence interval. During the RVS, many children with leprosy were detected, and 10% of all RVS new cases already had disability grade II. The population disability grade II rate due to leprosy was 9 per 10,000. Despite the fact that an active leprosy control programme had been carried out in the surveyed endemic area over a period of many years, the actual prevalence rate found was more than twice the known prevalence. Many children were found during the RVS, thus indicating continuing widespread transmission. In general, it seems that there is still a serious delay in detecting new cases under the routine programme. Consequently, there are substantial numbers of persons affected by leprosy in those districts in need of rehabilitation.     

The impact of leprosy control on the transmission of M. leprae: is elimination being attained?

In 1991 the World Health Assembly decided to 'eliminate leprosy as a public health problem' by the year 2000. Elimination was defined as reducing the global prevalence of the disease to less than 1 case per 10,000. In 2000 the World Health Organization (WHO) announced that elimination was reached globally. Conventionally control of disease is defined as the reduction of disease burden to a locally acceptable level. Elimination of disease is defined as the reduction to zero of the incidence in a defined geographical area, and eradication is defined as the permanent reduction to zero of the worldwide incidence of infection caused by a specific agent. In leprosy however, WHO limited elimination to control instead of transmission, by using prevalence instead of incidence of disease. Leprosy statistics usually report on prevalence and new case detection. Prevalence is linked to length of treatment, which has changed over time. Trends in new case detection rates only reflect trends in incidence rates when no changes occur in case detection, but in the past 25 years case detection in leprosy has been determined strongly by operational factors. For the leprosy elimination strategy it was assumed that MDT would reduce transmission of M. leprae, but there is no convincing evidence for this. Data for evaluating the impact of MDT on transmission are not readily available because leprosy has a long incubation period. Also declines in case detection may have other causes, such as BCG vaccination. Mathematical modelling of the transmission and control of leprosy showed that the elimination strategy reduces transmission slowly, with a predicted annual decline in incidence ranging from 2% to 12%. Early case finding was the key factor to attain this decline. Future projections of the global leprosy burden indicated that 5 million new cases would arise between 2000 and 2020, and that in 2020 there would be 1 million people with WHO grade 2 disability. It is concluded that substantial progress has been made to control leprosy, but when elimination of disease is defined as the reduction to zero of the incidence, leprosy is definitely not eliminated. To attain elimination of leprosy it is necessary to find effective interventions to interrupt transmission of M. leprae and practical diagnostic tools to detect levels of infection that can lead to transmission. This requires extensive research in the areas of epidemiology and microbiology.     

The current state of leprosy control activities in Sri Lanka

In Sri Lanka the overall prevalence of leprosy was 0.14 per 1000 population and the incidence 0.07 per 1000 population at the end of 1987. Although the endemicity is low in the island, disease transmission has not yet been achieved as the annual detection of new cases and the child rate has been gradually rising. The major activities of the leprosy control programme are case-finding, treatment and defaulter retrieval, health education, rehabilitation and training. The field programme is implemented through 15 specially trained paramedical workers. In addition there are 5 medical officers attached to the Anti-leprosy Campaign. The Director of the Anti-leprosy Campaign is in overall charge of the National Leprosy Programme and is also project manager for the Sri Lanka Emmaus Leprosy Control Project.     

Two cases of leprosy in Valladolid

Leprosy is still a major health problem on a worldwide level, and although it does not reach endemic levels on our continent, it seems that there is an upward trend due to the number of imported cases diagnosed each year. We present two cases of lepromatous leprosy diagnosed in Valladolid within a five-month period. The last reported case of this disease in our community was over 20 years ago.     

麻风病基本消灭阶段的流行病学特征

目的：分析麻风病基本消灭阶段流行病学特征,以指导麻风防治工作。方法：根据山东省历年的麻风病人登记表,分析比较麻风基本消灭阶段与防治初期的流行学特征。结果：麻风基本消灭阶段的流行病学特征与防治初期比较有显著变化;新病例呈散在分布;发病年龄显著升高;少年儿童发病显著减少;多菌型病例所占比升高。复发病例在新发病例中占比升高。结论：麻风病中、高流行区达到基本消灭麻风病后,应根据其流行病学特征采取相应防治对     

重复开展消除麻风运动地区的病例发现和患者临床情况分析

目的：观察湖南省西部2个麻风高流行县重复开展消除麻风运动对当地麻风患者发现及临床指标的影响。方法：收集自1997—2002年麻风新发病例，其中包括开展消除麻风运动年份的病例资料，对各年发现病人数，平均确诊年龄，畸残率，延迟期等进行比较分析。结果：从1997年至2002年共发现133例患者。平均每年发现22．2例，年发现率2．4/10万。1998年开展LEC时发现的新病人数是接近开展IEC前一年的2倍，以后新发现病人数减少到一个稳定的低水平，在2002年重复开展LEC时，发现数又是接近前一年的2倍。但与1998年首次开展LEC时发现数相比，减少了50％。新发病人的疾病延迟期平均为34．8月，疾病延迟期在开展LEC前后未显示有缩短或延长的趋势。133例患者中，35例有可见畸残(26．3％)。但新发现病人中2级畸残率从1998年的32．0％下降到2002年重复实施LEC时的12％。结论：作者认为重复实施消除麻风运动促进了当地某些流行病学指标的好转。     

Treatment outcome and impact of leprosy elimination campaign in Sokoto and Zamfara states, Nigeria

A Leprosy Elimination Campaign (LEC) was implemented in 37 districts of Sokoto and Zamfara states, Nigeria from 13 August to 30 November 1998. The campaign utilized intensive community mobilization and training of local health personnel to detect hidden leprosy cases. During 8 weeks of case finding, 160,127 persons were screened; 353 new cases of leprosy were detected and placed on MDT; 236 (67%) of new cases detected were classified as MB, 64 cases (18%) suffered visible deformities and 24 patients (6.8%) were children. Follow-up in December 1999 of patients placed on MDT revealed 97% PB and 96% MB cure rates, respectively. Detection of cases in communities led some community leaders to ask for repeat surveys in their communities. Repeat surveys continue to yield new cases. The authors recommend that LECs be maintained for 3 years to accelerate leprosy elimination in the region. The cost effectiveness and impact of LEC in Sokoto-Zamfara are discussed.     

Analysis on the detection of new leprosy cases before, during and after the year of leprosy elimination campaigns

To analyse the impact on of case finding of leprosy elimination campaigns (LECs), data on newly detected leprosy cases in a leprosy endemic area were collected before, during and after the year of LEC. The number of new leprosy cases detected during the year of LEC was significantly higher than previously. The number of newly detected cases after the year of LEC was similar to that of detected before the year of LEC in counties with persisting case finding activities. However, the number of newly detected cases after the year of LEC significantly decreased in counties without active case finding activities. The average distance from the homes of leprosy cases detected during LEC to the leprosy control unit at the count town was 62.8 km, which is farther than that of other leprosy cases detected before and after the year of LEC. The average time from disease onset to diagnosis of leprosy cases detected after the year of LEC shortened. The results also showed that carrying out LECs is unlikely to have a significant impact on the trend of case finding within a short time in local areas, but it may improve some indicators of leprosy patients and so promote leprosy control in local areas.     

The private GP and leprosy: a study.

In urban and rural areas alike, people in India tend to prefer private medical care to the existing government health services. Nevertheless, the large private health care sector has hitherto been virtually alienated from activities of public health importance including priority disease control programmes. This study of 106 private general practitioners (GPs), practising in low socioeconomic areas of Bombay, shows a gross lack of knowledge and awareness among private doctors about leprosy and also about the National Leprosy Control Programme. The possible reasons are discussed. Effective involvement of GPs in the National Leprosy Control Programme should facilitate both integration and better implementation of leprosy control activities. The study also highlights some areas for future interventions at both primary and secondary health care levels and the need for a strategy, based on larger studies, to train and make private doctors participate in controlling diseases of major public health concern like leprosy.     

Nerve function impairment in leprosy: design, methodology, and intake status of a prospective cohort study of 2664 new leprosy cases in Bangladesh (The Bangladesh Acute Nerve Damage Study).

The Bangladesh Acute Nerve Damage Study (BANDS) is a prospective cohort study designed to investigate epidemiological, diagnostic, therapeutic and operational aspects of acute nerve function impairment in leprosy. The study is based at a single centre in Bangladesh, in an area with a high prevalence of leprosy. The centre, Danish Bangladesh Leprosy Mission, has a well-established vertical leprosy control programme. In this paper, the study design and methodology are described, together with definitions of nerve function impairment (NFI) used in this and subsequent papers. The study recruited 2664 new leprosy cases in a 12-month period. The male:female ratio is 1.25:1, and 17.61% of the cohort are under 15 years of age. In all, 83.33% of the cohort are paucibacillary (PB), and 16.67% multibacillary (MB). However, the MB rate amongst males is 19.72%, and amongst females is 12.85%, despite an equal period of delay to diagnosis. 55% of patients presented for treatment within 12 months of developing symptoms 6.12% of the total number of cases were smear positive, and 36.71% of the MB cases were smear positive. 9.61% of the total number of cases were graded as having World Health Organisation (WHO) disability grade 1, and 5.97% had grade 2. Amongst MB cases, 27.48% had WHO grade 1 disability present, and 18.24% had grade 2 present, compared with 6.04% and 3.51%, respectively, amongst PB cases. A total of 11.90% of the cohort had sensory NFI of any kind, and 7.39% had motor NFI. Ninety patients presented with NFI needing treatment (3.38%), and of these, 61 (67.78%) had silent NFI. MB patients had a prevalence of reaction/NFI needing treatment nearly 7 times higher than PB cases (15.32% amongst MB; 2.30% amongst PB), and males nearly double that of females (5.67% amongst males, 2.96% amongst females). The most commonly affected nerve by function impairment was the posterior tibial (sensory) with 6.46% of nerves affected (9.38% of patients), followed by the ulnar nerve with 3.23% of nerves impaired (5.56% of patients). Future research and publications, building on this foundation, will focus on the following areas: the incidence of NFI and reactive events, the risk factors for developing NFI, and the response to treatment of patients developing acute NFI.     

Curing the stigma of leprosy

The stigma of leprosy is a real phenomenon in many people's lives that affects their physical, psychological, social and economical well-being. There are many causes for this damaging image of leprosy. There is no one easy answer to dispelling this image; it is something that has to be done in partnership with communities and patients. Many papers document the effects of stigma, but few discuss or trial solutions. Education and media campaigns counteract false beliefs about leprosy and raise awareness of new advances in the field. Leprosy care is increasingly provided in an integrated setting showing patients and their communities that leprosy is not a disease apart. Physical and socio-economic rehabilitation is worthwhile in restoring self worth and status in the community and helps patients to find employment. Group counselling can allow those with leprosy to talk about their feelings and experiences to empower one another. Gradually attitudes towards leprosy are changing, but there is still much to be done if the underlying menace of stigma is to be dealt with. We as health professionals must be prepared to make the first move and give that first touch. Certainly more research is needed. In the highly endemic countries the road to elimination may yet be long. Perhaps with effort we will one day be able not only to treat the disease, but also to cure the stigma of leprosy, and make that road an easier one.     

Report of the national leprosy elimination campaign (NLEC) of Bangladesh, 1999

A national leprosy elimination campaign (NLEC) was implemented country-wide in all the 64 districts of Bangladesh for 6 days from 7 to 12 February 1999. The campaign was jointly funded by the Government of Bangladesh (GOB)/World Bank (US$250,000) and the remaining US$381,000 was provided by other international non-governmental organizations (NGOs). A total of 44,400 health workers and community volunteers were directly involved in the campaign. In all, 60,878 suspected leprosy cases were identified during the campaign, of whom 31,433 were examined and 2435 were confirmed as leprosy cases. The remaining suspects are expected to be examined within the next 2 months. Details of the new cases detected are given in Table 8. The impact of NLEC has been significant, the number of cases detected during NLEC being 20% of the annual case detection in 1998. About 52% of the total population were directly contacted through a rapid house-to-house survey and over 90% of the population was targeted through extensive use of electronic/print media and various information, education and communication (IEC) activities.     

重复开展消除麻风运动对当地新发现病人情况的影响

目的:观察贵州省兴义市重复开展消除麻风运动对当地新发现麻风病人的影响.方法:收集1996～2004年新发现麻风病人的有关资料进行比较分析.结果:9年共发现麻风病人166例,平均每年发现18.4例,年均发现率为2.65/10万.1999年首次开展消除麻风运动后3年,新病人中的2级畸残率和延迟期呈明显下降趋势,低于开展前3年的水平.两次开展消除麻风运动时的畸残率和平均延迟期均达较高水平,提示该地区虽两次开展消除麻风运动但麻风流行程度仍处于较高水平.结论:重复实施消除麻风运动可促进某些流行病学指标的好转,应反复多次开展.     

Epidemiological pattern of leprosy in Ethiopia: a review of the control programmes

Leprosy control started in a limited area of Ethiopia in 1956. Extended coverage of the country was achieved in the early seventies. Review of the data from the control projects since 1976 revealed that leprosy is a disease of the Ethiopian highlands where prevalence rates as high as 7 per thousand have been recorded in some provinces, while the cumulative national average for the last 13 years was 2.6 per thousand. The paucibacillary form was predominant. However, unlike other African countries, a relatively high proportion of multibacillary leprosy was found in Ethiopia. The male-to-female ratio was 2:1 with the highest prevalence in the 15-44 years age bracket. Detection rates for new cases have shown a gradual decline since 1982, a year before multiple drug therapy (MDT) was introduced into the country. For the last 5 years the number of new cases has stabilized at 4700/year. These trends probably reflect a general reduction in the prevalence of leprosy in the country, while the conspicuous decline in 1982 is most likely related to discharge of cases during screening before MDT. The new villagization policy of Ethiopia with its effective reorganization of the populations is believed to make control programmes and supervision of MDT easier and presumably more effective. Similarly, more reliable prevalence and incidence studies could be undertaken with success.     

Acro-osteolysis prior to diagnosis of leprosy

lysis (bone resorption) has been observed in a heterogeneous group of congenital and acquired bone disorders. Leprosy is the main cause of peripheral neuropathy leading to acro-osteolysis in endemic countries. Pure neuritic leprosy, a less common form of the disease, is difficult to diagnose. Two unrelated leprosy patients with acropathy whose disease began as pure neuritic are discussed.     

Leprosy: a problem solved by 2000?

It is now the year 2001, and in many endemic regions leprosy remains a public health problem by any definition. It is clear that defining leprosy purely by prevalence side-steps some of the real issues. There is still much to do to solve the problem of leprosy. Control programmes require better tests for early diagnosis if leprosy is to be reduced much further. Treatment of the infection and of reactions is still far from ideal, whilst an effective vaccine would be valuable in high-risk regions. Research into the true incidence in each endemic area is essential, and control programs of the future will need a more detailed understanding of the transmission of M. leprae to permit new logical interventions. Leprosy remains a devastating disease. Much of the damage that it inflicts is irreversible, and leads to disability and stigmatization. This is perhaps the greatest problem posed. It is easy to dwell on the successes of the elimination campaign, so diverting attention from those populations of 'cured' patients who still suffer from the consequences of infection. Leprosy should be regarded as a problem unsolved so long as patients continue to present with disabilities. WHO has carried out a highly successful campaign in reducing the prevalence of leprosy, and this needs to be acknowledged, but what is happening to the incidence in core endemic areas? Maintaining this success, however, may be an even greater struggle if funding is withdrawn and vertical programmes are absorbed into national health structures. We must take heed of the historian George Santayana, 'those who cannot remember the past are condemned to repeat it'. We should take the example of tuberculosis as a warning of the dangers of ignoring a disease before it has been fully controlled, and strive to continue the leprosy elimination programmes until there are no new cases presenting with disability. The World Health Organisation has shown that leprosy is an eminently treatable disease, and has prepared the ground. The leprosy elimination campaigns truly are 'at a height... ready to decline'. Can it be that this is the chance to take leprosy 'at the flood'? If so, perhaps an extension of the elimination programs beyond the year 2001 would indeed 'lead to fortune'.