WHO Leprosy Elimination Project: Status Report 2003 · The leprosy elimination programme forms part...

WHO Leprosy Elimination Project: Status Report 2003

9

Table 7: Leprosy Situation in the Eastern Mediterranean Region (EMRO) at the end of 2002 (latest available figures)Country Point

PrevalenceCases detected during the year 2002

Prevalence rate per 10 000

Detection rate per 100 000

Afghanistan 222 19 0.1 0.1

Bahrain 36 6 0.6 1.0

Djibouti 27 2 0.4 0.3

Egypt 2,405 1,318 0.3 1.9

Iran 326 82 0.0 0.1

Iraq

Jordan 0 0 - -

Kuwait 0 12 - 0.6

Libya 8 7 0.0 0.1

Morocco 340 60 0.1 0.2

Oman 6 8 0.0 0.3

Pakistan 1,983 1,202 0.1 0.7

Qatar 7 7 0.1 1.1

Saudi Arabia 28 39 0.0 0.2

Somalia 447 151 0.4 1.4

Sudan 1,639 1,361 0.5 4.5

Syria 3 3 0.0 0.0

Yemen 422 388 0.2 2.1

Table 9: Leprosy Situation in the Western Pacific Region (WPRO) at the end of 2002 (latest available figures)Country Point




American Samoa 6 0 0.8 -

Cambodia 588 740 0.5 6.5

China 3,623 1,646 0 0.1

Federated States of Micronesia

79 108 6.5 89.3

Fiji 2 4 0 0.5

Hong Kong 39 6 0.1 0.1

Korea 543 22 0.1 0

Lao People’s Dem. Rep.

162 155 0.3 2.8

Malaysia 955 181 0.4 0.8

Marshall Islands 48 52 7.3 78.8

New Zealand 3 - 0.1

Papua New Guinea

620 552 1.3 11.2

Philippines 3,334 2,479 0.4 3.2

Samoa 8 12 0.4 6.6

Singapore 25 4 0.1 0.1

Solomon Islands 26 26 0.6 5.7

Tonga 0 0 - -

Vanuatu 8 6 0.4 3.1

Vietnam 1,269 1,158 0.2 1.4Table 8: Leprosy Situation in the South East Asian Region (SEARO) at the end of 2002 (latest available figures)Country Point




Bangladesh 8,143 9,844 0.6 7.5

Bhutan 33 13 0.2 0.6

Timor Leste 249 281 2.8 31.3

India 344,377 473,658 3.2 44.4

Indonesia 16,837 12,377 0.8 5.8

Maldives 19 29 0.6 9.9

Myanmar 5,494 7,386 1.1 16.0

Nepal 7,980 13,830 3.3 56.5

Sri Lanka 1,639 2,214 0.9 11.6

Thailand 1,905 1,000 0.3 1.6

WHO, in conjunction with the national pro-grammes, has undertaken a country-by-country reassessment of the prevailing situation in the major endemic countries. This section of the report provides short profiles of some of the major endemic countries

BrazilOverview of the programme

Brazil has a well developed though complex health care system, which reflects the roles and responsibilities of different political levels - the national, the 27 federal units (or states), and 5,560 municipalities. The federal government finances about 70 percent of the public health services, the balance coming from the states and municipalities. There is also considerable inequity in access to medical services, favouring cities and the more populated Southeast.

The leprosy elimination programme forms part of the dermatology services and was designed as a semi-vertical system with leprosy coordinators in individual states. In 1998 less than 25% of local health facilities were in a position to diagnose and

tries combined represents 83% of the global prevalence and the prevalence rate is 3.4 per 10 000. India alone represents around 64% of prevalence and 76% of new cases world-wide. At the state level in India, there are eleven endemic states (having a prevalence of more than 10 000 and also a prevalence rate higher than 2 per 10 000), which together represent more than 90% of the disease burden in India. These states are: Andhra Pradesh, Bihar, Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh and West Bengal.

Major endemic countries


10

Brazil

Development Indicators 1997 2000 2001

Population, total (millions) 163.8 170.1 172.4

Population growth (annual %) 1.3 1.3 1.2

National poverty rate (% of population) .. .. ..

Life expectancy at birth (years) 67.4 68.1 68.3

Fertility rate (births per woman) 2.3 2.2 2.2

Infant mortality rate (per 1,000 live births) 37.4 32 31

Under 5 mortality rate (per 1,000 children) .. 38 36

Child malnutrition, weight for age (% < 5 yrs) .. .. ..

Child immunization, measles (% < 1 year) 99 99 99

Access to affordable essential drugs %* .. 0-49 ..

Human Development Index (HDI) value * .. .. 0.777

Illiteracy total (% age 15 and above) 14.4 13.1 12.7

Illiteracy female (% of age 15 and above) 14.7 13.2 12.8

GNI per capita, Atlas method (current US$)* 4,740 3,630 3,070

GDP growth (annual %)* 3.3 4.4 1.5

Aid per capita (current US$)* 1.8 1.9 2

Source: World Bank, World Development Indicators database, April 2003 and UNDP , Human Development Report 2003.*SeeGlossaryfordefinitionofterms

Leprosy Situation MB PB Total

Cases detected during 2002** 16,569 15,583 38,390

Child cases (<15 years) amongst new cases 2,545

Grade 2 disability amongst new cases 1,601

Cases registered for treatment at end of year 78,403

Source: Ministry of Health, 2003** Individual MB and PB data incomplete for some states

Leprosy elimination in Brazil

Key indicators

• Second most endemic country in the world

• Prevalence and prevalence rate: 78,403 (4.2 / 10 000 population)

• New cases and detection rate: 38,390 (22.3 / 100 000 population)

• Geographic focus: impoverished states of North /Northeast

Highlights of activities 2003• National campaign (BBC, PAHO/WHO,

Health Ministry, MORHAN) to encour-age early help seeking behavior

• Improved awareness of the signs of leprosy

Constraints to eliminating leprosy • Limited access to leprosy diagnosis and

treatment in endemic areas• Non adherence to fixed duration treat-

ment• Very centralized programme

Remedial actions needed• Accelerate decentralization of leprosy

services in the endemic areas• Urgent need to increase geographical

coverage of MDT • S i mp l i f y i n f o r mat i o n s y s t em

(SINAN)

treat leprosy. This was clearly a major obstacle to the elimination of leprosy. In November 1998 the National Council of Municipal Health Secretaries (CONASEMS) adopted a resolution to provide leprosy diagnosis and treatment at every health facility. The framework for this new partnership was provided by a tripartite agreement between the Min-istry of Health, CONASEMS, and the Pan-American Health Organization (PAHO)/WHO.

A task force representing all key players (the National Leprosy Programme of the Minis-try of Health, the municipal health secretaries (CONASEMS), PAHO/WHO, MORHAN (a social mobilization organization for leprosy) and leprosy experts) was created in January 1999 to guide the decentralization process. The Task Force also oversaw the production and distribution of informa-tion and training kits for use in the municipalities, funded jointly by the Ministry of Health, WHO and the Novartis Foundation. Efforts focused on the priority municipalities in the states of Bahia, Piaui, Tocantins, Pernambuco, and Rio de Janeiro. Sig-nificant progress was made to that end. A major

step was the inclusion of leprosy as part of the basic health package for primary health facilities with an administrative resolution passed in 2001.

However, the momentum of the task force has been lost, as responsibility for tuberculosis has been added to the mandate of the task force and the team was expanded.

Brazil has the second highest number of regis-tered patients in the world after India. Prevalence rates at the national level are over four times the world elimination target. There has been a steady increase in new cases over the past twenty years and since 1998, over 38 000 new cases have been


11

detected every year. However, leprosy elimina-tion campaigns have not contributed significantly in detecting “hidden” cases.

Prevalence rates vary considerably within the country. About 56% of registered cases come from the North and North eastern regions, as do 40% of new cases. These states have limited public health resources, especially in comparison with the richer states in the south. One-third of all hospitals are in the Southeast, and there are more than twice as many people per doctor in the impoverished Northeast state of Piauí as there are in São Paulo. Many health facilities in the high endemic states of the North and Northeast still do not provide leprosy services.

Key constraintsThe Brazilian leprosy programme is still man-

aged as a highly specialised programme with limited emphasis on integration within the general health services. There are indications from LEM exercises that patients are kept on the treatment registers long after completion of the standard course of MDT. This explains the high prevalence/detection ratio showing that the reported prevalence is sig-nificantly inflated. At the same time, however, a general process of political decentralisation is still ongoing in the country which will devolve control of public health services (including their funding) to the municipalities, and this offers some scope to increase geographical coverage with MDT.

Remedial action needed If Brazil is to meet the elimination target, special

action is urgently required to tackle the high level of transmission (especially in the North and North-east regions), to increase the geographic coverage with MDT and to make the programme more public health orientated. The large majority of new cases occur in underserved populations with little access to information and health care. As a result many remain undetected, or are detected too late.

The basic groundwork is in place, and leprosy is now part of the primary health care package. The challenge now is to work with local health services and empower them to provide leprosy services. The task force should be reactivated to continue the work initiated in the past. There is also a need to stress the importance of adherence to standard guidelines for treatment duration and updating of registers.

Leprosy awareness campaign 2003WHO commissioned the BBC World Service

Trust to conduct a national radio and television leprosy awareness campaign in Brazil in 2003, in partnership with the Brazilian Ministry of Health,

MORHAN, Pastoral da Crianca and Brazil’s major broadcasters. The month-long campaign consisted of three TV spots and ten radio spots. It ran from 29 January until 27 February 2003. Globo, SBT, Bandeirantes and Rede TV), in addition to ten other national television partners, reported the broadcast-ing of the campaign TV spots more than 7,000 times nationally. In addition, over 2,800 radio stations across Brazil were given the campaign spots.

The purpose of the campaign was to raise awareness about leprosy (called hanseniase in Brazil), its symptoms and treatment. The campaign emphasised three key messages

• How to recognize leprosy signs.• Leprosy can be treated and cured.• A person on treatment is not contagious,

and can continue to have a normal life while being treated.

Closing voiceovers added:

• Treatment is free at a Public Health Centre.

• Call Telehansen for more information, with the Telehansen number.

The campaign had broad penetration across the five regions surveyed, reaching 64% of the adults surveyed.The estimated national reach of the campaign was 73.6 – 84.7 million people. The campaign successfully communicated its mes-saging brief. Nearly three-quarters (74%) of those exposed to the campaign recalled at least one of the campaign’s main messages.

The campaign had a significant and positive impact upon the awareness of leprosy and its symptoms. Levels of hanseniase awareness and knowledge of specific symptoms are approximately 30% higher among those exposed to the campaign, compared to those not exposed. The campaign also had a positive effect on perceptions about leprosy treatment.

Correct beliefs regarding leprosy treatment and tolerance for people being treated are at approxi-mately 30% higher levels among those exposed to the campaign, compared to those not exposed.

IndiaOverview of the programme

Since the 1950s India has accorded a high pri-ority to the control of infectious diseases through a series of centrally administered disease control pro-


12

India


Population, total (millions) 965.4 1,000 1,000


National poverty rate (% of population) .. 28.6 ..

Life expectancy at birth (years) 62.2 62.8 63

Fertility rate (births per woman) 3.3 3.1 3

Infant mortality rate (per 1,000 live births) 71 68 67




Access to affordable essential drugs %* .. .. 0-49


Illiteracy total (% age 15 and above) 45.1 42.8 42


GNI per capita, Atlas method (current US$)* 420 450 460

GDP growth (annual %)* 4.4 4 5.4

Aid per capita (current US$)* 1.7 1.5 1.7



Cases detected during 2002 140,936 250,839 391,775

Child cases (<15 years) amongst new cases 57,943

Grade 2 disability amongst new cases 8,353


Source: Ministry of Health, 2003

grammes, which included leprosy. In general, the performance of these centrally managed schemes has been uneven with important limitations at both the central and state levels.

There are eleven endemic states which, taken together, represent more than 90% of the disease burden in India, and have a prevalence rate of 4.6 per 10 000. They are Andhra Pradesh, Bihar, Chhat-tisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh and West Bengal. These eleven states also repre-sent a significant proportion of the registered cases and newly detected cases globally and highlight the importance of effective implementation of intensi-fied elimination strategies there.

Prevalence and detection trendsThe latest available information indicates that

there were 344 377 cases registered for treatment (prevalence rate 3.2 per 10 000), of which 473 658 new cases were detected during 2002 (detection rate 46 per 100 000). Among the new cases, the proportion of MB cases was 35% (167 095 cases); the proportion of children under 15 years old was

15% (70 463 cases); the proportion of female was 34% (160 946 cases); and the proportion of cases with grade 2 disabilities was 1.8% (8 526 cases).

The proportion of child cases remains high. This can be ascribed to one or more of the following fac-tors: continued high transmission, intense elimina-tion activities targeted to this age group like school surveys, or the factor of “over-diagnosis”. The low proportion of females could indicate a bias in detec-tion. The proportion of grade 2 disability cases is low in India compared to other countries.

The proportion of Grade-2 disability is slightly reduced to 1.8% (2.1% in the previous year), and the child proportion has declined from 16.3% to 14.9% over the same period. The female proportion of new cases however is still low, at 34%.

A structural issue, specific to the national pro-gramme in India, has been the use of new case detection targets. This practice dates back to the early days of the vertical programme and was intended as a way of ensuring wider geographical coverage of treatment and improving worker effi-ciency. At best, this has been a crude management tool when used as the sole parameter to assess the performance of leprosy workers. At worst, detec-tion targets have grossly inflated the real extent of the leprosy problem, encouraged unnecessarily high demands for MDT and - most worrying of all - even cast doubts on the feasibility of the elimina-tion strategy itself.

There is some evidence to suggest that the recent shift away from targets is already starting to bear fruit in India, and this is reflected by the 23% fall in new case detection in the twelve months up to March 2003, This period includes a fourth round of leprosy elimination campaigns, when new case detection would normally be expected to rise when compared with non-campaign years.

The new data represents a significant fall in detection even at the global level, as India rep-resents close to 76% of the global burden of the disease. Targets for new case detection have no relevance once diagnosis and treatment are fully integrated into the primary health care system, and the decision by the Indian programme not to set new case detection targets at the national level for the year 2003 is highly significant.

Although any such short term analysis of detec-tion trends is fraught with potential problems, these encouraging results may indicate that the backlog of cases within the community is finally being cleared up, more realistic estimates are now being made, and new case detection rates will now continue to fall.


13

Table 10: India: Leprosy Situation 2002-2003State or Union

TerritoryRegistered prevalence at end of

March 2002

New cases detection April 2002 - March 2003 Detection rate per 100 000

population

Registered prevalence at end of

March 2003


populationNew MB

casesNew PB cases

Total new cases

MB % Female %

Child %

Grade 2 disability %

Andhra Pradesh 24,947 7,823 29,435 37,258 21.00 39.40 25.71 1.13 47.95 19,667 2.53

Arunachal Pradesh 136 87 39 126 69.05 14.29 2.38 1.59 11.03 103 0.90

Assam 2,283 981 589 1,570 62.48 23.25 7.32 5.61 5.69 1,531 0.56

Bihar 93,709 30,267 64,294 94,561 32.01 40.08 16.11 1.48 108.60 74,871 8.60

Chattisgarh 22,930 7,529 10,939 18,468 40.77 34.76 11.28 2.65 85.93 15,482 7.20

Goa 324 121 173 294 41.16 30.27 20.75 1.36 21.28 428 3.10

Gujarat 7,309 4,078 7,486 11,564 35.26 44.85 15.43 1.28 21.95 7,392 1.40

Haryana 646 453 265 718 63.09 20.33 2.37 4.46 3.24 550 0.25

Himachal Pradesh 234 228 52 280 81.43 27.50 2.14 6.79 4.46 256 0.41

Jharkhand 35,587 10,902 18,080 28,982 37.62 35.31 16.42 1.83 103.34 18,207 6.49

Jammu & Kashmir 702 356 216 572 62.24 22.90 7.52 4.55 5.40 633 0.60

Karnataka 12,843 4,656 8,415 13,071 35.62 41.44 21.28 1.01 24.02 10,353 1.90

Kerala 2,297 1,097 1,433 2,530 43.36 41.62 16.13 3.20 7.81 2,185 0.67

Madhya Pradesh 13,834 7,300 9,270 16,570 44.06 33.38 7.70 3.77 26.28 12,027 1.91

Maharashtra 32,318 13,740 34,809 48,549 28.30 44.31 19.79 1.53 48.19 29,680 2.95

Manipur 142 47 61 108 43.52 34.26 9.26 3.70 4.29 92 0.37

Meghalaya 70 50 28 78 64.10 35.90 7.69 12.82 3.21 86 0.35

Mizoram 33 4 19 23 17.39 47.83 0.00 0.00 2.45 9 0.10

Nagaland 60 33 25 58 56.90 17.24 0.00 5.17 2.65 41 0.19

Orissa 33,329 12,067 26,282 38,349 31.47 0.00 15.99 1.72 101.45 27,660 7.32

Punjab 1,300 809 547 1,356 59.66 20.50 3.54 5.97 5.39 1,192 0.47

Rajasthan 4,284 1,291 649 1,940 66.55 32.16 3.56 3.25 3.27 4,325 0.73

Sikkim 66 18 22 40 45.00 7.50 5.00 2.50 7.00 41 0.72

Tamil Nadu 22,255 5,906 18,861 24,767 23.85 38.50 17.84 1.18 39.04 14,813 2.34

Tripura 175 35 45 80 43.75 28.75 2.50 12.50 2.44 103 0.31

Uttar Pradesh 85,631 39,952 50,634 90,586 44.10 34.02 8.33 1.51 52.13 71,647 4.12

Uttaranchal 1,912 788 1,458 2,246 35.08 29.88 8.37 2.00 25.58 1,655 1.88

West Bengal* 32,871 13,131 18,887 32,018 41.01 25.87 12.89 2.44 38.63 22,432 2.71

A & N Islands 87 23 37 60 38.33 25.00 15.00 3.33 16.06 48 1.29

Chandigarh 343 239 84 323 73.99 23.53 6.81 12.38 33.54 239 2.48

D & N Haveli 254 102 166 268 38.06 45.15 13.06 0.00 111.01 122 5.05

Daman & Diu 28 8 10 18 44.44 5.56 5.56 0.00 10.44 7 0.41

Delhi 5,921 2,916 3,059 5,975 48.80 25.87 4.05 7.13 40.23 6,339 4.27

Lakshadweep 28 4 23 27 14.81 37.04 22.22 0.00 43.17 29 4.64

Pondicherry 265 54 171 225 24.00 44.89 13.33 0.89 22.26 132 1.31

Total 439,153 167,095 306,563 473,658 35.28 33.98 14.91 1.80 44.37 344,377 3.23

*For 5 districts of West Bengal information pertains to February 2003.

Leprosy Elimination Monitoring

The TAG Sub-group on Monitoring and Evalu-ation, held in New Delhi, India, in early February 2001, recommended that LEM should be conducted on an annual basis for Group 1 countries, and on a selected basis for Group 2 and 3 countries. It was also recommended that LEM be conducted at the State level in India and Brazil, in consideration of their geographical and population sizes.

For the first LEM exercises conducted in June 2002, the National Institute for Health & Family Wel-fare (NIHFW) based in New Delhi, was identified by the Government of India as the implementing

agency. From the preparation to the implementation phase, it included all the major partners, Govern-ment of India, WHO, DANLEP, DFIT, NLR and TLM. The survey covered the 11 priority states and two additional States (Delhi and Uttaranchal Pradesh). A sample of 77 districts was drawn up, in which a sample of urban and rural health facilities was selected. This first large scale LEM served as base-line data for similar exercises to be carried out in the coming three years, and monitor the progress being achieved towards elimination. The second round of LEM was completed in August 2003. In addition, for the first time, the programme undertook a sys-tematic exercise to validate new case detection. A summary of the reports is attached as Annex 1.


14

MDT supply management in IndiaIndia absorbs about 70% of the total MDT pro-

cured by WHO annually and any significant over or under estimate of requirements can cause major problems. In order to facilitate the MDT distribution at the State level,

WHO ships directly to the Government Medi-cal Store Depots in Karnal (Haryana), Mumbai, Kolkata, Hyderabad and Chennai. Over recent years, observations by the NLEP/WHO State and Zonal coordinators in the high endemic states have shown that MDT drug stocks at the health facility

and/or district levels are often inappropriate, with either a shortage or an excess of stock. The reason may be partly due to the transition period of inte-gration, where MDT indent and storage are not yet integrated with the general drug supply.

By mid-2002 it was clear to WHO that India already had sufficient stocks of adult blister packs to last the rest of the year. The national programme acknowledged that it had surplus stocks of MDT and agreed to a postponement of around 30-40% of its planned shipments to 2003. The two charts below show the MDT supply to India over the

MapofIndiadeletedtoreducefilesize


15

Table 11: Epidemiological indicators, IndiaYear or

Indicator

And

hra

Prad

esh

Bih

ar

Chh

attis

garh

Jhar

khan

d

Kar

nata

ka

Mad

hya

Prad

esh

Mah

aras

htra

Oris

sa

Tam

il N

adu

Utta

r Pra

desh

Utta

ranc

hal

Prad

esh

Wes

t Ben

gal

Tota

ls

Prevalence trends in 12 priority states, 1998-2002 (rates per 10 000)19981999200020012002

5.54.7

53.73.2

11.718.918.712.910.9

7.98.78.57.7

10.8

714.614.610.912.9

2.32.42.62.72.4

9.25.45.8

32.3

4.93.33.73.13.3

23.97.6

11.27

8.9

7.15.3

54.13.5

4.14.76.14.3

5

21.82.11.72.2

4.86.95.32.7

4

3.67.38.85.45.3

New Case Detection trends in 12 priority states, 1998-2002 (rates per 10 000)1997-19981998-19991999-20002000-20012001-2002

7.38.9

88.86.4

15.136.721.616.6

14

12.918.812.110.713.7

10.92518

14.316.6

3.55.14.43.33.9

5.59.7

83.1

3

6.85.66.64.6

5

23.312.4

1812.312.9

6.97.5

10.25.35.1

428.6

6.85.26.6

12.42.72.22.9

4.99.26.84.45.7

417.611.97.37.4

Case Finding Indicators in 12 priority states in 2002% children% MB cases% of SSL PB% Grade 2

2719.8

5.31.4

15.434.4

0.12.2

12.637.1

2.73

14.239.8

12.4

24.929.5

70.8

848.5

2.65

22.728.5

5.91.6

15.730.6

6.41.7

27.418.123.4

1.4

9.343.7

11.9

7.838.3

0.22.3

13.837.7

0.92.6

22.134.5

5.52.9

Median delay in diagnosis

11.3 10.1 9.7 13 5.6 10.8 7.2 5.1 9.4 7.7 10.6 8 8.6

% females 41.5 35.2 36.4 28.5 46.8 34.8 47.3 40.2 44.5 38.6 NA 31.8 38.7

Child proportion trends in 12 priority states, 1998-20021997-19981998-19991999-20002000-20012001-2002

27.927.529.219.9

27

14.510.412.9

1615.4

15.71616

15.312.6

17.511.714.416.914.2

24.526

25.824.424.9

11.412.111.28.8

8

22.823.924.427.822.7

16.817

17.417.515.7

2731.731.624.827.4

7.81.78.4

10.79.3

4.64.75.2

11.87.8

1711.812.812.313.8

19.623.923.128.222.1

MB proportion among new cases trends in 12 priority states, 1998-20021997-19981998-19991999-20002000-20012001-2002

19.617.519.618.319.8

34.336.538.437.134.4

35.132.123.9

3637.1

34.138.639.935.839.8

25.921.927.929.529.5

43.338.552.948.148.5

20.123.224.932.228.5

2525.227.129.230.6

14.716.917.1

2618.1

43.939.545.544.343.7

52.149.246.545.938.3

38.636.537.941.837.7

32.832.333.735.434.5

Disability grade-II proportion trends in 12 priority states, 1998-20021997-19981998-19991999-20002000-20012001-2002

21.61.81.41.4

4.34.53.22.22.2

4.63

3.333

5.24.83.42.32.4

1.40.8

11

0.8

75.54.75.5

5

1.31.61.62.11.6

2.12.11.91.81.7

2.52

1.41.81.4

5.31

2.92.41.9

16.94.34.32.62.3

4.74.13.33.12.6

46.23.72.52.9

Single Skin Lesion proportion trends in 12 priority states, 1998-20021997-19981998-19991999-20002000-20012001-2002

NA30.712.813.5

5.3

NA1.53.22.80.1

13.716.1

7.76.82.7

NA2.2

22.7

1

37.432.319.811.2

7

3.93.2

64.42.6

35.532.426.419.7

5.9

19.118.717.315.6

6.4

44.251.239.541.323.4

5.86.74.66.7

1

11.56

4.48.90.2

17.35.53.72.90.9

14.717.114.514.2

5.5

Female proportion trends in 12 priority states, 1998-20021997-19981998-19991999-20002000-20012001-2002

4645

45.445

41.5

42.231.141.138.935.2

43.553.636.237.436.4

31.537.4

3542.728.5

31.319.321.528.346.8

34.332.633.839.134.8

47.148.146.548.547.3

NANANANA

40.2

NA39.938.544.344.5

23.937.242.835.938.6

NANANANANA

NANANANA

31.8

NANANANANA

period 2002-2003 before and after the adjusted shipment schedules. The second adjusted chart more closely approximates to the actual “demand” for MDT drugs over the period.

WHO will continue to closely monitor the MDT

stock situation in India in order to avoid shortages, or excess stocks being held unnecessarily at the sub-national levels. It is expected that this com-ponent of the programme will be better managed in the future, with the implementation of the new simplified information and reporting system.


16

MadagascarOverview of the programme

Administratively, Madagascar is divided into 6 federal provinces, which are subdivided into 28 regions, 111 sub-regions, 1 392 communes and 13 000 villages. There are currently 2 500 primary health facilities in Madagascar giving a ratio of 1 health facility for every 5 000-7 000 inhabitants. About 60% of the regions are difficult to access, especially in the rainy season.

The leprosy elimination programme is a semi-vertical programme. The director of the leprosy/ tuberculosis programme at the central level, is sup-ported by leprosy-TB managers at the provincial level. However at the district and peripheral level, leprosy is integrated into the general health serv-ices, although many primary health workers have not been trained and are often not in a position to diagnose and treat leprosy.

The first serious effort to eliminate leprosy from

Madagascar


Population, total (millions) 14.1 15.5 16


National poverty rate (% of population) 73.3 .. ..





Child malnutrition, weight for age (% < 5 yrs) 40 .. ..


Prevalence of HIV (female, % ages 15-24) .. .. 0.2



Illiteracy total (% age 15 and above) 36 33.5 32.7



GDP growth (annual %)* 3.7 4.8 6





Child cases (<15 years) amongst new cases 823

Grade 2 disability amongst new cases 437



Madagascar was intiated in 1992 with training basic health staff and the introduction of MDT. LECs and SAPELs were conducted in order to reach the many remote and high endemic areas in the country. In 2000 the groundwork to decentralize leprosy services was started but was derailed due to the political tensions in the country. In 2003 leprosy elimination efforts have regained momentum and a national plan for the elimination of leprosy has been developed.

Since 1992 there has been a steady increase in the number of new cases with a peak in the years 1997 and 1998 as a result of the LEC and SAPEL campaigns. At the end of 2001 all the regions, except for Antananarivo had a prevalence rate higher than 4 per 10 000 inhabitants. With the updating of the registers at the end of 2002 there was a 64% drop in registered cases. In total 67 371 cases had been detected in the past decade with most cases detected in the second half of the decade.

Key constraintsLeprosy elimination efforts in Madagascar face

numerous problems including poor geographical access to many districts, particularly in the rainy seasons, fear of leprosy, lack of trainined health staff and poor management of MDT supplies, inad-equate logistical support at the district level and

Leprosy Elimination in MadagascarKey indicators (2003)

• Prevalence and prevalence rate: 6,602 ( 4.0 / 10 000 population)


• Geographic focus: entire country except capital district

Highlights of activities 2003 • Updating of registers • Development of plan to intensify lep-

rosy elimination effortsConstraints to eliminating leprosy

• Poor geographical access to many health facilities especially in rainy season

• National leprosy programme needs to be restructured

Remedial actions needed• Strengthen and restructure leprosy

programme • Make leprosy diagnosis and treatment

available at all health facilities • Social mobilization in hyperendemic

areas


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Mozambique



Population growth (annual %) 2 2.1 2

National poverty rate (% of population) 69.4 .. ..





Child malnutrition, weight for age (% < 5 yrs) 26.1 .. ..




Illiteracy total (% age 15 and above) 59.4 56 54.8

Illiteracy female (% of age 15 and above) 74.7 71.3 70



Aid per capita (current US$)* 57 49.6 51.7








centres, and the creation of Provincial Task Forces in the five northern provinces.

Constraints to eliminating leprosy The leprosy programme remains vertical and

the health service coverage is very low particularly in the high endemic areas. The MDT distribution system is still highly centralised and inflexible, with patients having little access to treatment in their own community.

Remedial actions neededIn the WHO regional meeting in Maputo in Sep-

tember 2000, various strategies were developed including the organization of two-week leprosy information campaigns for social mobilization to promote active community participation, train-ing of staff and decentralization of activities and resources at the level of the provinces. The Maputo meeting also recommended that MDT coverage should be extended to all the health centres, or even to all the villages in the high endemic zones. The participation of community health workers in the management of leprosy cases and flexibility in the supervision of the treatment were recom-

MozambiqueOverview of the programme

The health sector in Mozambique has suffered from the prolonged civil war, low levels of financ-ing and limited technical capacity. The coverage of health service is still very low and estimated at around 42%. The infant mortality rate is one of the highest in the world. The leprosy elimination pro-gramme is a vertical service but is moving gradually towards decentralization and integration.

Leprosy is highly endemic in Mozambique with a national prevalence rate at the beginning of 2003 of 3.6 per 10 000 population. The disease is concentrated mainly in 5 provinces with prevalence rates ranging from 2.5 per 10 000 (in Manica) to 10.3 per 10 000 (Nampula). The geographic coverage of leprosy services is very poor in the endemic districts and ranges from 2% in Manica to 60% in Zambezia. This low coverage is linked with the poor coverage of health services in these provinces. The supervision of workers is inadequate and not well organized.

With WHO’s encouragement, a National Task Force was created and started functioning in the first quarter of 2000. A plan of action to accelerate leprosy elimination activities was formulated in an informal meeting held in Geneva in May 2000 with the participation of all the partners. Various solu-tions were developed including a survey to evalu-ate the geographic coverage of MDT services in the villages, conducting LECs in the provinces in the north combined with the opening of new MDT

limited knowledge of the technical guidelines. Many taboos and myths still surround leprosy which will need serious efforts in developing IEC strategies for changing the negative image of leprosy in the communities.

Remedial actions neededThere is an urgent need to make leprosy

services available at all health facilities (whether public or those run by religious organizations). This will involve training of health staff, MDT supplies, using WHO guides, coordination and supervision. In addition a special effort must be made in the hyperendemic districts to update registers and conduct social mobilization programmes to detect hidden and new cases.

This will require restructuring the leprosy elimi-nation programme at the national and provincial level to strengthen the support to the basic health centres. To train provincial teams to guide and lead the activities in the periphery and thereby help ensure the availability of leprosy diagnosis and MDT at all health facilities.


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mended as a means of encouraging patients to report regularly for treatment. Information cam-paigns in the community should insist on the early signs of leprosy and the availability and free supply of leprosy drugs.

As a first step leprosy services will be made available in all 419 health facilities in the high endemic provinces of Nampula, Cabo Delgado, Zambezia, Niassa and Manica. This will involve the training of health staff as well as reorganizing the supervision. In addition, social mobilization efforts will be initiated in the 81 districts of these provinces to encourage people to seek diagnosis and treat-ment. Another key activity will be the updating of the leprosy registers in the three most endemic provinces.

In view of the poor coverage of health services, alternative means to improve access to MDT have been initiated in the past, including the creation of MDT distribution points as well as involvement of volunteers to suspect leprosy. The impact of these activities still needs to be assessed.

Import regulations made by the Mozambique authorities in 1996 are still in place, which continue to cause lengthy delays in WHO shipments.

Leprosy elimination in MozambiqueKey indicators (2003)



• Geographic focus: five endemic prov-inces in the North

Highlights of activities 2003 • Implementation of MDT distribution

points • COMBI (Communication for behavioral

change) to encourage people to check their skin for leprosy

Constraints to eliminating leprosy • Poor geographical access to leprosy

services due to limited coverage of health facilities

• Highly centralized programmeRemedial actions needed

• Improve patients access to leprosy services by making MDT available in all existing facilities

• Developing innovative ways to extend coverage of MDT services

• Decentralizing leprosy services • Involving volunteers in recognizing

leprosy

NepalOverview of the programme

Leprosy is considered a public health problem in Nepal owing to the magnitude of the disease burden and its hideous consequences. In the last couple of years, besides well-planned regular activities of case detection and case holding, other special activities were also carried out such as intensifying IEC activities, skin camps and launching leprosy elimination campaigns. All these activities have helped a lot to reduce the disease burden in the country.

Key constraints Poor security conditions in the field and difficult

terrain has led to a large number of defaulters.

It is urgent in Nepal to conduct an in-depth analysis to gain a clearer picture of the leprosy situation with special attention to districts faced with security problems . In addition, Regional and District health authorities should be strengthened

Nepal


Population, total (millions) 21.4 23 23.6







Child malnutrition, weight for age (% < 5 yrs) .. .. 48




Illiteracy total (% age 15 and above) 61.7 58.3 57.1

Illiteracy female (% of age 15 and above) 79.2 76 74.8












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and more involved in the development of plans of action for leprosy elimination. Continued training of health workers, together with strengthening supervision and monitoring by management train-ing workshops for district health officers, introduc-tion of accompanied MDT services to improve cure rate, and intensified case finding activities such as focused LECs are the key strategies to intensify leprosy elimination activities.

Remedial actions neededAccessibility is to be further improved by

strengthening the integration of MDT services up to the sub-health post level in all the Regions. IEC materials and simplified guidelines for elimination in local language will be provided to all health facili-ties to improve the MDT services and community awareness. In addition, mass media will be used to promote community awareness and to reduce the stigma against those who have contracted the disease.

TanzaniaOverview of the programme

The Tanzania National Tuberculosis and Lep-rosy Programme (NTLP) was launched by the Ministry of Health in July 1977. The Programme is funded by the Tanzanian government and external donors from both governmental and non-govern-mental organisations. There is structural and func-

Tanzania










Child immunization, measles (% of < 1 year) 73 78 83



Illiteracy total (% age 15 and above) 28.5 25 24






Leprosy Situation 2002 MB PB Total






tional integration of leprosy control services into the general health care services and a dedicated and well financed National Central Coordinating Unit. The NTLP is integrated in the existing pri-mary health care system, with all health providers responsible for early case detection, appropriate treatment and case holding. The managerial and supervisory staff at the national, regional and district level ensure adequate technical competence of all health workers involved.

The MDT distribution system apparently works well throughout the country, from the National Central stores, to the Regional Drug stores, and onward to the Districts and Health facilities. National strategic plans for leprosy elimination are drawn up on an annual basis.

Tanzania achieved full coverage of registered leprosy patients with WHO recommended MDT very late as the programme used Isoprodian based regi-mens, supplied by GLRA until 1997.

The registered leprosy prevalence in Tanzania has been declining over the years from 26,630

Leprosy elimination in NepalKey indicators (2003)



• Geographic concentration: entire coun-try except capital district

Highlights of activities 2002 • Updating of registers • Development of plan to intensify lep-


• Poor geographical access to many health facilities especially in rainy season and due to security problems

• National leprosy programme needs to be restructured depending on the security situation.

Remedial actions needed• Strengthen and restructure leprosy

programme • Make leprosy diagnosis and treatment

available at all health facilities


20

Leprosy elimination in TanzaniaKey indicators (2003)



• Geographic focus: 13 out of 21 regions

Highlights of activities 2002 • LEM highlighted problems and updating

of registers • Development of plan to intensify lep-


• Out-of-date guidelines, procedures and registers

• Poor geographical access to many health facilities

Remedial actions needed• Update guidelines, procedures and

registers• Conduct LECs and SAPELs in high

endemic areas• Make leprosy diagnosis and treatment

available at all health facilities • Community awareness of leprosy

cally difficult to access areas, refugee populations and nomadic populations.

Key constraintsDespite substantial NGO involvement over

many years, a LEM study in 2002 found many weaknesses in the national programme. The reporting and recording formats were outdated and treatment registers were not up-to-date.

The guidelines were printed in 1995 and need to be updated to include recent internationally accepted leprosy control policy changes such as the duration of treatment for MB patients. MB patients are still treated for 24 months, in spite of the fact that the NTLP had accepted the policy of 12 MB doses recommended by the WHO Expert Committee in 1997. The guidelines also combined the old method of classifying of leprosy patients (TT, BT, BL LL) instead of the WHO standard classifica-tion of PB and MB.

MDT drugs are supplied by WHO according to the various registered categories of leprosy patients, i.e, MBA, MBC, PBA, and PBC. In the NTLP reporting formats in Tanzania, the LEM found that there were no columns for indicating the leprosy data according to the WHO classification, which made it practically impossible to order the correct quantities of MDT blister packs.

Other weaknesses include low community awareness on leprosy, low MDT coverage in some areas due to displaced populations and difficult to access areas, and an over-treatment of leprosy patients with MDT drugs.

Remedial actions requiredThere is a need to “clean” (update) the treat-

ment registers. While new cases, relapses, and patients resuming treatment have continued to be added to the registers and considered to reflect the existing prevalence for that particular period, those patients having completed treatment, who had died or been transferred to other areas, or had defaulted were never removed from the reg-isters. The registered caseload therefore was grossly inflated. This has in turn led to a much higher demand for MDT drugs than necessary, and possible wastage due to drugs expiring before they are used.

Key actions which need to be undertaken urgently include updating guidelines and regis-ters, conducting LEC and SAPEL in high endemic areas, promoting community awareness on leprosy disease, expanding the coverage of MDT services and building the capacity of local health workers to diagnose and treat leprosy.

in 1985 (prevalence rate 11.8/10,000) to about 7,000 in 2003 (prevalence rate 2/10,000). Despite the decline in the number of leprosy cases, the proportion of new patients with disabilities has not changed significantly over the years (15% disabil-ity grade 2, falling to 11% after starting LECs).

This indicates that there is a delay in the diag-nosis of leprosy in the National Programme and by implication, many hidden cases. Moreover, leprosy case detection has remained stable over the years (between 3 000 and 4 000 cases per year).

Leprosy Elimination Campaigns and SAPELs have been carried out from 1998 to 2002 leading to an increase in the annual case load from 3,963 reaching 7,000 cases during 2002. The proportion of children among the newly diagnosed leprosy patients is still high (11%) in 2002. The MB pro-portion of the registered leprosy patients is 58%, indicating a high source of leprosy infection.

The ratio between registered prevalence and case detection rate is 1.12, denoting that patients take longer time than the recommended to com-plete MDT. By the beginning of 2003, 13 regions out of 21 in the country had a leprosy prevalence rate above 1/10 000 population. In addition, some regions have special situations such as geographi-

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