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On the Road to Eliminating Leprosy: Meeting the Challenge
Penny Grewal, Novartis Foundation for Sustainable Development, Switzerland
 For
those involved in the fight against leprosy, these are exciting times.
Tremendous progress has been made since the development of a cure for the
disease. The statistics show how far we have come. The World Health Organisation
(WHO) has estimated that in the last 15 years over 11 million people have been
cured, while about 4 million have been protected from developing deformities.
These figures, though impressive, cannot express the suffering which has been
alleviated. And yet we still have some way to go. At end 1999, WHO estimated that
about 2.5 - 2.8 million people suffered from leprosy, most of them still hidden
- despite the fact that  treatment
is free of charge everywhere. The reasons are numerous. Simple physical access
to treatment is often a problem due to inadequate health infrastructures and
limited/no involvement of general health workers in diagnosing and treating
leprosy. A further complication is the web of fear and prejudice which continues
to shroud leprosy. The Global Alliance to Eliminate Leprosy, established about
two years ago, is focusing its efforts on making treatment more accessible and
as easy as possible for the patient, while addressing these hidden cases and
persuading those infected to seek treatment. (A glimpse
at the history of leprosy)
Where do we stand?
MDT has changed the face of leprosy. It cures patients in 6 months or a year
depending on the form of the disease, interrupts its transmission immediately
and through early cure, prevents disabilities.
 
 MDT
is
provided in user-friendly monthly blister packs, which have greatly assisted
dispensing and patient compliance, while protecting the drugs against insects
and moisture. The field packs containing 8 patient packs, each with six months'
treatment, simplify logistics and protect the drugs from damage during
transportation.
Today 90% of the disease burden is concentrated in just six countries: India,
Brazil, Myanmar, Nepal, Madagascar and Mozambique. India alone accounts for 64%
of registered cases. Over the past 35 years, the global prevalence rate
increased from 8.4 cases per 10,000 population in 1966 to a peak of 12 per
10,000 in 1985. Since then, there has been a steady decline reaching the
elimination target, set by the World Health Assembly, of less than 1 per 10,000
at the end of 2000. At this low level of infection, it is assumed that the
disease is likely to disappear naturally, as it already has in many parts of the
world.
Today leprosy is a public health problem (i.e. where there is a prevalence
rate higher than 1 per 10,000 inhabitants) in only 15 countries mainly in Asia,
Latin America and Africa. In Africa these are Angola, Central African Republic,
Democratic Republic of Congo, Côte d'Ivoire, Guinea, Liberia, Niger,
Madagascar, Mozambique and United Republic of Tanzania.
In recent years about 700,000 new patients are being detected annually with
the widening network of leprosy services. Most of these cases had contracted the
disease some time ago and are only now starting treatment. Many more are still
to be detected and need to be treated with MDT in order to eliminate leprosy as
a public health problem.
The strategy
 The
priority now is to further extend the coverage of MDT, while at the same time
spreading awareness of the treatment in affected communities, and encouraging
people to seek treatment.
National health authorities are now taking steps to provide leprosy diagnosis
and treatment in basic health centres, bringing treatment closer to patients so
that they can avoid long journeys and undue expense. Previously leprosy control
had been in the hands of specialised services. However the effectiveness of
simple diagnostic techniques (testing the insensitive areas of skin, usually
with a pointed object) as well as the ease of prescribing and dispensing the
correct treatment have made the provision of leprosy services in local centres
by basic health personnel possible.
 Integrating
leprosy services into the basic health services greatly extends the network of
leprosy coverage and thus improves patients' access. Implementing the change has
meant running extensive training programs in endemic countries to familiarise
health personnel at all levels with leprosy. It has the important added
advantage of keeping health personnel 'thinking leprosy' when treating patients
with skin problems in the future, when the prevalence of the disease will
probably have fallen even further. It has also meant simplifying logistics to
ensure availability of MDT.
To encourage people with possible leprosy symptoms to come forward for
treatment, it is necessary to break the vicious circle, in which fear and
ignorance leads leprosy sufferers to delay seeking timely treatment, often
leading to disabilities that intensify social stigma. So in place of the old
images of fear, disfigurement and social exclusion, we are working to project a
'positive' image for the disease. The communication campaigns have drawn on
commercial marketing principles to create 'demand' in affected communities.
Using everything from dramas and jingles in the mass media to talks and
information initiatives among remote communities, the key messages have been
hammered home in many countries.
Key messages
In short, these are:
- Be alert to the signs of leprosy. These are easily identifiable. Most
importantly, the skin patches are insensitive - a sign unique to leprosy.
1-5 skin patches? It's PB leprosy. More than 5? It's MB leprosy
- Don't delay. Anyone with suspicious skin symptoms should go and get a
diagnosis as soon as possible. And don't worry. Early treatment prevents
disabilities. The patient cannot transmit the disease to others.
- Follow the treatment. This is extremely straightforward. Simply take the
pills, which are accompanied by clear instructions and carry on with your normal
life. As MDT has proved to be safe and effective, patients can choose to take
the whole course of treatment home after consultation with a health care
provider. Patients choosing to do this are accompanied by a family member or
friend to help them with compliance.
Meeting the challenge …
At the initiative of WHO, the Global Alliance for Leprosy Elimination was set
up in November 1999 to ensure that a common strategy based on the successful
experience of past leprosy elimination efforts was energetically implemented.
Its goal is the elimination of the disease from every country by the year 2005.
The formation of the Global Alliance has enabled a wider degree of
cooperation and the deployment of greater resources internationally, including
the continued free provision of MDT. This cooperation makes the elimination of
leprosy an excitingly realistic prospect. Of course, our optimism has to be
tempered with caution. Many of the remaining high endemic areas present
particular problems in terms of poor infrastructure and difficult access, and
marginalised populations, as well as limited communication networks. We will
also need to work hard to keep leprosy on the agenda when there are many other
pressing demands on scarce public health resources.
Achieving the goal of elimination will accomplish much more than simply
resolving a public health problem. It will enhance the credibility and
confidence of local health services and put in place systems that can be used to
tackle other diseases.
We have the exceptional combination of resources and will. With the
technology and experience at our disposal, it would be unforgivable to miss this
historic opportunity.
Further information:
www.novartisfoundation.com www.novartisfoundation.com
www.who.int/lep
WHO Weekly Epidemiological Record 4 January 2002 No77.
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| The
Global Alliance to Eliminate Leprosy (GAEL)
The Alliance brings together the
mainplayers in the fight against leprosy
- the governments of leprosy endemic countries (policy and
implementation),
- the WHO (technical support and guidance),
- the Nippon Foundation ($24million for implementation)
- Novartis/ the Novartis Foundation for Sustainable Development (free
MDT for all patients ca. $30 million and country level support).
GAEL also works closely with patients, communities and other agencies
interested in tackling leprosy, such as the Danish International
Development Assistance (DANIDA) and the World Bank. |
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A glimpse at history
After centuries during which the only way of combating the disease was by
isolating leprosy sufferers from society, the first breakthrough came in 1873,
when a Norwegian doctor, Armauer Hansen first identified the rod shaped
bacterium, mycobacterium leprae, which causes leprosy. The efforts to find a
cure for the disease lasted for decades and were made more difficult by the fact
that the bacteria could not be cultivated in the laboratory and until 1960,
there were no animal models. There were periods of intense disappointment, as
when a pattern of resistance emerged in the 1960s to the first anti-leprosy
drug, dapsone, that had first been introduced in 1946.
The cure that was ultimately recommended was a combination therapy,
comprising 3 drugs, each preventing resistance to the other, dapsone,
clofazimine (Lamprene®) and rifampicin (Rimactane®), known as multidrug
therapy (MDT). The non infectious, paucibacillary (PB) form of leprosy is
treated with dapsone and rifampicin, and the less common, infectious
multibacillary (MB) form with a combination of all three drugs. MDT treatment
renders patients non-infectious almost immediately. In the 20 years since MDT
was recommended by WHO as the standard leprosy treatment, there have been very
few relapses, virtually no reports of drug resistance and the common side
effects are usually mild and temporary.
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