WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA
ORGANISATION MONDIALE DE LA SANTE BUREAU REGIONAL DE L’AFRIQUE
ORGANIZAÇÃO MUNDIAL DE SAÚDE ESCRITÓRIO REGIONAL AFRICANO
REGIONAL COMMITTEE FOR AFRICA
AFR/RC54/INF/DOC.2 28 June 2004
Fifty-fourth session Brazzaville, Republic of Congo, 30 August–3 September 2004 Provisional agenda item 12.3
ORIGINAL: FRENCH
LEPROSY ELIMINATION IN THE WHO AFRICAN REGION Information Document Executive Summary 1. Leprosy is an infectious disease sustained by overcrowding and poverty. It causes deformation, mutilation and disability in the majority of people affected. It is rife among poor populations, impoverishing them even further. Currently, more than five million people (patients and their families) in the African Region are affected by the social and economic consequences of leprosy. 2. The development of an efficacious treatment using a combination of three drugs (multidrug therapy) and the fact that treatment is free of charge led to rapid cure of the disease. That prompted the World Health Assembly to decide, by its Resolution WHA 44.9 passed in 1991, to eliminate leprosy as a public health problem. 3. Member States’ political commitment to eliminating leprosy found expression in the implementation of a national leprosy elimination programme in each country. Regular evaluation of the national programmes rendered achievable the objective of leprosy elimination as a public health problem defined as a prevalence rate below one case per 10 000 inhabitants. As a result, over 800 000 leprosy cases were cured in the Region in the last decade. However, although 37 countries have reached the threshold for leprosy elimination, three other countries remain very endemic and are at risk of inability to attain the set threshold of one case per 10 000 inhabitants by 2005. 4. Despite the progress made, challenges remain and should be met in order that all countries of the Region reach and maintain the threshold of leprosy elimination as a public health problem. To that end, Member States should continue to support leprosy elimination programmes and make them a priority. In addition, they should integrate leprosy surveillance into the surveillance of other diseases and provide their programmes with the national resources needed. It is also necessary that the countries develop community-based activities and reduce the stigmatization of leprosy patients in society.
CONTENTS Paragraphs INTRODUCTION ............................................................................................................................................. 1–6 JUSTIFICATION FOR THE LEPROSY ELIMINATION PROGRAMME .................................. 7–9 LEPROSY ELIMINATION STRATEGY .................................................................................................... 10 SITUATION OF LEPROSY ELIMINATION ..................................................................................... 11–14 PERSPECTIVES .................................................................................................................................................. 15 CONCLUSION .............................................................................................................................................. 16–18 Annexes Pages 1. 2. 3. 4. Forms of leprosy in the African Region .……………………………………………………..5 Leprosy situation in countries of the African Region, October 2003 .......................................6 Trends of leprosy prevalence and detection rates in the African Region since 1991 ...............7 Resolution AFR/RC44/R5 Rev.1: Elimination of leprosy in the African Region ....................8
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Introduction 1. Nearly 50 000 new cases of leprosy are detected each year, and between 10% and 13% of the cases carry visible infirmities. An estimated one million people in the economically productive age group in the African Region are disabled. 2. People affected by leprosy are strongly stigmatized due to the deforming and disabling complications of the disease which prevent patients from working and contributing to the development of their country. Very often, patients are treated as social outcasts. The disease therefore contributes to impoverishment of its victims. 3. Leprosy remains a disease of poverty. It affects poor people living in unhygienic conditions and consuming unhygienic foods. However, there is efficacious, acceptable and affordable treatment that has proven its worth and forms the basis of the leprosy elimination strategy. 4. In 1991 and 1994, WHO adopted resolutions WHA44.9 and AFR/RC44/R5 Rev.1 to eliminate leprosy as a public health problem by the year 2000. In 1999, an analysis of the global situation of leprosy was carried out and showed that although substantial progress had been made towards reducing the prevalence of the disease, the set objective had yet to be achieved. 5. In November 1999, the third international conference on leprosy elimination in Abidjan, Côte d’Ivoire, recommended that: (a) (b) (c) the target year for leprosy elimination be postponed from 2000 to 2005; leprosy elimination should be nationwide in all countries; plans be developed to intensify or accelerate leprosy activities in countries where that was necessary.
6.
This document aims to assess the situation of leprosy elimination in the African Region.
Justification for the Leprosy Elimination Programme 7. In 1990, the number of leprosy cases in Africa was estimated to be more than 1 500 000. Over 25% of the cases had visible mutilations. Leprosy was a public health problem in 42 of the 46 Member States. 8. In the 1980s, 30% of leprosy patients had disfigurement as a complication of the disease. The disfigurement prevented the patients from contributing to the national output of their respective countries. Given their status as leprous, the patients could not participate in the economic life of their communities. It was estimated that over 5 million leprosy patients and their families in Africa have become economically dependent and socially scarred because of the disease. In addition, communities rejected leprosy patients and sometimes their families. In some countries, the children of leprosy patients could not attend school, and daughters were denied the right to marry.
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9. The advent of multidrug therapy and its efficacy in leprosy treatment played a crucial role in the development of a leprosy elimination strategy and in the decision to develop a leprosy elimination programme. Leprosy Elimination Strategy 10. A strategy for leprosy elimination was developed. Components of the strategy were: (a) (b) (c) (d) (e) (f) (g) early diagnosis and treatment of all new cases; treatment of all cases using multidrug therapy (MDT) in accordance with the WHOrecommended protocol; organization of regular and adequate case treatment; community involvement in case management; availability of leprosy drugs and accessibility of treatment to all communities and localities; strengthening of case surveillance, preventive action and disability management; strengthening of partnership and coordination of interventions in countries.
Situation of Leprosy Elimination 11. The 42 endemic countries in the WHO African Region embarked on leprosy elimination programmes as soon as resolution AFR/RC44/R5 Rev.1 was adopted. The thrusts of the programmes are the following: (a) training of all officials of health districts of the endemic countries in leprosy elimination programme management and district health workers in leprosy case management; screening and appropriate treatment of leprosy cases in public and private primary health care services; widespread use of the WHO-recommended multidrug therapy protocol for leprosy treatment; free distribution of leprosy drugs by WHO thanks to the support of Sasakawa Memorial Health Foundation (SMHF) until 1999 and of Novartis Foundation from 2000 onwards; implementation of Special Action Projects for the Elimination of Leprosy (SAPEL) to address the problem of access to some localities and villages that have no health services; conducting leprosy elimination campaigns to give leprosy a better image in communities and to facilitate case finding, management and reintegration in communities; establishment of a reliable information system for better assessment of the magnitude of the disease in countries;
(b) (c) (d)
(e)
(f)
(g)
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(h)
regular monitoring and periodic evaluation of national plans to assess the progress made towards leprosy elimination in the Region.
Outcomes 12. The Leprosy Elimination Programme has resulted in the following outcomes: (a) at least 70 Special Action Projects for the Elimination of Leprosy were developed in countries, enabling 20 million people to gain access to leprosy control services and reaching out to 2000 new cases of leprosy in the African Region; geographical coverage of leprosy elimination programmes increased from 7% in 1992 to 80% in 2003; similarly, the number of new cases found each year increased from 20 000 in 1992 to 45 000 in 2003, peaking at 56 000 cases in the Region in 1998; in the most endemic health districts, communities participate in case finding and management as part of the leprosy elimination campaign; social integration of leprosy patients is becoming increasingly easier; the number of countries with prevalence rates exceeding two cases per 10 000 inhabitants fell sharply from 42 in 1992 to four in 2003, representing a reduction by 90%; cumulative cured leprosy cases increased from 50 000 to 800 000 over the past ten years; leprosy elimination is monitored in each country that has a prevalence rate above two cases per 10 000 inhabitants; the average prevalence rate in the Region dropped from six cases in 1992 to less than one case per 10 000 inhabitants in 2001; in the African Region, 37 of the 42 highly endemic countries have crossed the leprosy elimination threshold and two other countries are about to do so; leprosy prevalence, as recorded in health services in the Region, decreased from 560 000 in 1992 to below 60 000 in 2003, representing a reduction by nearly 90%.
(b)
(c)
(d)
(e) (f) (g) (h) (i)
Constraints 13. The main constraints in leprosy elimination in the African Region are: (a) difficulties in integrating leprosy elimination activities into the routine activities of health facilities; some partners prefer that leprosy control remain a vertical programme running in parallel with health services and are working toward that end, and this hampers ownership of the leprosy elimination process by the national health system; slackened commitment and effort of countries that have reached the elimination threshold; continuing dependence of leprosy elimination activities on external funding.
(b) (c)
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Challenges 14. To ensure effective leprosy elimination, the States and partners should: (a) coordinate their efforts to reach the threshold of less than one case per 10 000 inhabitants, especially in the three most endemic countries, namely, Angola, Madagascar and Mozambique; (b) intensify advocacy for allocating national resources to leprosy programmes; (c) maintain and even consolidate leprosy elimination achievements in Member States; (d) ensure full and sustainable integration of leprosy control activities in primary health care services. Perspectives 15. To ensure the success of the leprosy elimination programme, there will be need: (a) to develop and implement a plan to intensify leprosy elimination activities in the three countries that still have high prevalence rates; (b) to include leprosy in the integrated disease surveillance programme in order that all possible new cases can be promptly detected and appropriately treated; (c) to set up a system of procurement, distribution and regular monitoring of leprosy drugs in countries and integrate it in the national system of drug supply to health facilities; (d) to develop community-based activities for early management of new leprosy cases. Conclusion 16. The different resolutions calling for leprosy elimination boosted general mobilization for leprosy control. Implementation of the leprosy elimination strategy has helped achieve the elimination objective in most of the countries. Plans to accelerate and intensify activities will, no doubt, help eliminate leprosy in countries that are still very endemic. 17. However, difficulties still exist in coordination of efforts in countries, organization of programme management, continuing allocation of resources for leprosy control and integration of leprosy activities in primary health care services. 18. Strengthened political commitment of countries, development of partnerships and implementation of integrated disease surveillance will ensure effective and sustainable elimination of leprosy in all countries of the Region.
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ANNEX 1 FORMS OF LEPROSY IN THE AFRICAN REGION
Leprosy is an infectious disease caused by Mycobacterium leprae. Its clinical manifestation often starts with a skin lesion. It is curable without sequelae if treatment is early enough. The two most common forms of the disease are paucibacillary leprosy (PB) and multibacillary leprosy (MB).
Fig. 1: Paucibacillary leprosy (PB)
Fig. 2: Multibacillary leprosy (MB)
AFR/RC54/INF/DOC.2 Page 6 ANNEX 2 LEPROSY SITUATION IN COUNTRIES OF THE AFRICAN REGION, OCTOBER 2003 Country Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Congo Côte d'Ivoire Dem. Republic of Congo Eritrea Éthiopia Gabon Gambia Ghana Guinea Guinea-Bissau Equatorial Guinea Kenya Lesotho Liberia Madagascar Malawi Mali Mauritania Mauritius Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone South Africa Swaziland Tanzania Togo Uganda Zambia Zimbabwe TOTAL 1
Date 15-Mar-03 12-Mar-03 2-Apr-03 8-Jul-02 17-Jun-03 26-Mar-02 27-Mar-03 26-Mar-03 10-Apr-03 26-Mar-03 16-Apr-02 5-Feb-03 6-Aug-03 2-May-03 13-Mar-03 2-Jul-02 26-Mar-03 2-Apr-03 1-Apr-03 18-Feb-03 11-Jul-02 19-Aug-02 18-Apr-02 17-Apr-03 28-Feb-03 27-Mar-03 11-Jul-02 19-Mar-03 26-Mar-02 10-Mar-03 4-Mar-03 22-Apr-02 1-Feb-03 17-Jun-03 9-Apr-03 27-Jun-01 20-Mar-02 19-Mar-02 11-Mar-03 9-Jun-03 15-Apr-03 4-Feb-02 5-Jun-02 6-Jun-03 17-May-02 29-May-03
Population Prev1 31 471 000 0 14 416 610 5 249 6 097 000 294 1 597 000 43 11 937 000 928 6 695 000 364 15 085 000 893 428 000 12 3 615 000 750 7 651 000 547 694 000 150 2 943 000 384 17 109 000 51 654 000 3 719 000 62 565 000 1 226 000 1 305 000 20 212 000 8 185 820 1 247 000 442 000 30 080 000 2 219 000 2 930 000 15 942 000 10 925 000 11 234 000 2 670 000 1 166 000 19 680 000 1 726 000 10 730 000 108 945 000 7 235 000 147 000 9 481 000 77 000 4 854 000 40 377 000 1 008 000 33 517 000 4 629 000 21 778 000 9 169 000 11 669 000 632 482 430 1 552 4 859 27 5 022 44 96 886 902 111 32 197 20 685 6 602 456 531 49 2 7 136 10 1 026 5 890 14 0 500 6 449 163 4 5 235 320 714 753 45 53 952
Det2 0 4 272 392 2 943 213 1 597 4 388 233 171 362 1 358 5 037 27 4 523 17 72 1 063 1 234 50 18 180 20 560 5 482 473 609 104 2 5 830 10 1 207 5 078 8 0 500 2 751 52 1 4,656 279 668 764 4 49 216
R/Pre3 0.00 3.64 0.48 0.27 0.78 0.54 0.59 0.28 2.07 0.71 2.16 1.30 0.91 0.94 0.07 0.80 0.36 0.74 0.44 1.10 0.89 0.72 0.06 0.09 2.34 4.14 0.42 0.47 0.18 0.02 3.63 0.06 0.96 0.54 0.02 0.00 0.53 0.78 0.93 0.04 0.04 1.56 0.69 0.33 0.82 0.04 0.85
R/Det4 0.00 29.63 6.43 0.13 7.90 3.18 10.59 0.93 10.73 3.05 24.64 12.30 7.94 9.75 0.73 7.23 1.39 5.52 5.26 15.07 4.01 4.07 0.60 0.90 19.11 34.39 4.33 5.42 3.90 0.17 29.62 0.58 11.25 4.66 0.11 0.00 5.27 2.60 15.47 0.13 0.10 13.89 6.03 3.07 8.33 0.03 7.78
NMC5 0 2975 253 620 1020 3 253 166 155 893 2687 18 14 50 785 653
NCC6 0 485 33 37 209 1 16 7 7 97 568 0 1 3 115 165
NCD 27 0 565 85 80 144 0 52 20 14 113 666 4 0 12 38 74
16 369 3743 238 1 3679 723 4331 7
6 80 823 0 0 599 0 474 0
3 55 437 0 0 479 155 593 4
130 43 1 0
69 38 0
435 3 24 134
74 2 3 932
75 0 3 775
Prevalence; 2Detection; 3Prevalence rate; 4Detection rate; 5 New multibacillary cases; 6New cases among children; 7New cases with disability grade 2
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ANNEX 3 TRENDS OF LEPROSY PREVALENCE AND DETECTION RATES IN THE AFRICAN REGION SINCE 1991
7.0
6.0
Recorded cases 5.0
4.0
3.0
2.0
New cases 1.0
0.0 Recorded cases** New cases**
1991 6.6 0.8
1992 3.7 0.7
1993 2.8 0.7
1994 2.1 0.9
1995 1.7 0.9
1996 1.4 0.8
1997 1.29 0.89
1998 1.29 0.89
1999 1.06 0.82
2000 1 0.86
2001 0.93 0.79
2002 0.92 0.81
Year
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ANNEX 4 RESOLUTION AFR/RC44/R5 REV. 1: ELIMINATION OF LEPROSY IN THE AFRICAN REGION The Regional Committee, Recalling resolutions WHA44.9 and AFR/RC42/9 concerning leprosy; Expressing satisfaction with the progress so far made in leprosy control in the Region; Recognizing that political commitment has increased in all our Member States; Further recognizing that national and international nongovernmental and other organizations increased support to countries to develop national action plans; Having considered the Regional Director’s report on leprosy elimination; 1. CONGRATULATES the Regional Director on the excellent and concrete actions taken towards the implementation of multidrug therapy among Member States; 2. CALLS UPON Member States to: (i) (ii) increase and sustain the political commitment to further expanding to 100% MDT coverage of leprosy; strengthen management capacity and capability within national programmes, particularly at district level;
(iii) strengthen health education activities through various approaches including community participation, particularly in respect of the rehabilitation and social reintegration of leprosy patients; 3. CALLS UPON international, governmental and nongovernmental organizations as well as private voluntary foundations to continue supporting leprosy control activities in the African Region; 4. CALLS UPON the Regional Director to target activities towards improving leprosy control in the 10 most endemic countries by: providing training in management at district level using training modules; developing monitoring and evaluation tools; providing direct consultants’ support; encouraging NGOs to sustain financial support to programmes and promoting health systems for capacity building in Member States;
5. REQUESTS the Regional Director to monitor the progress of the programme and report regularly to the Regional Committee.