WORLD HEALTH SANITAIRES MONDIALES PROGRESS IN LEPROSY CONTROL THROUGH MULTIDRUG THERAPY PROGRES DANS LA LUTTE ANTILEPREUSE PAR LA POLYCHIMIOTHERAPIE - ·· ,,. I . Vol. 44, No. 1, 1991 World Health Organization Organisation mondiale de la Sante Gen eve ... The World Health Organization is a specialized agency of the Liniled Nations with primary re'lpOnsibility for international health matters and public health. Through this or- ganization, which wa:-. created in 1948. the health professionals of some 160 countrie'!. exchange their knowledge and experience wilh lhe aim of making possible the attain- ment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a :,,ocially and economically pro<lm.:tive life. 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Starting with Vol. 41 (1988), the Quarll'rly contains articles in l'ither French nr English with a summary in both languages. Annual subscription .................................. . Sw. fr. 90.- Price per copy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sw. fr. 24.- Material jh>m the Quarterly may he reproduced providing due acknowledgement is made. L'Organisation mondiale de la Same (OMS), crCCe en 1948, est une irn,titution ~pccia- lisCc des Nation'j Unie~ a qui incomhe, sur le plan intemational, la re:-.ponsabilitC princi- palc en matiC:rc:: de questions sanitaires et de sant<: publique. Au sein de I 'OMS. lcs pro- fessionnels de la sanlC! de 4uelque 160 pays &:hangcnt de~ connais:-.ances et de~ donntes d'expcricnce en vue de faire acceder d'ici l'an 2(Xl0 tous le::~ habitants du rnonde a un niveau de sante qui leur permette de mener une vie socialcment et <!Conomiquement pro- ductive. Grace:: a la cooperation technique qu'elle pratique avec !)es Etat:-. Mernhrcs ou qu'clle stimulc cntre euic I 'OMS :-. 'ernploie a promouvoir la mise sur pied de ':iervices. de sante complets, la prevention et t'cndiguement de,; maladies, I 'amelioration de I 'environne- ment, le developpement de:-. personnels de sant<:, la coordination et le progres de la rc- cherche biomCdicale et de la recherche \Ur le!) :-.ervices de :-.ante, ainsi quc la planifica- rion et !'execution des programmes de santC. Le vaste domaine ol1 ~ 'excrcc I 'action de I 'OMS comporte des activitCs trCs di verses: Jeveloppement des soins de \ant<: primaire!-. pour que toutes les populations pui~'jenl y avoir acc<!s; promotion de la santC maremelle et infantile; la lutte contre la malnutrition; lutte contre le paludi':ime et d'autres maladies tran-:,,missibles, dont la ruberculose et la 11:pre; I 'eradication de la variolc· ctant realisee, promotion <le la vaccination de massc contre un certain nombre d'autres maladies Cvitable'j: amClioralion de la sante mentale: approvbionnement en eau saine; formation de per!)onnel<, de santC de routes categories. 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Le Rapport trimcstricl dl' .\latistiqu£'.'. saniraires mondia/es remplace (depuis 1978) le Rapport de statisriquc•s sanitairc.\· mondiale.\· (pllblit- depuis 1967) et son prCcurseur le Rapport epid£'mioloiiqu£' l'I dtmographique (publie <lcpui!-. 1947). [I presence des analyses dCtaillCcs sur des sujets sp<!cifique:-. d'int6ret courant. A compter du Vol. 41 ( 1988). le Trimestril'I prCsente <le:-. articles originaux en franfrais ou en anglais, accompa- gnCs d'un rCsumC dans les deux langue:-.. Prix de 1 · abonnement annuel ............................. . Fr. s. 90.- Le numCro ....................................... . Fr.,. 24.- La reproduction d' extraits du Trimestriel est autorisee, sous re- serve d' indication de la source. IX ISSN 0043 - 8510 PRINTED IN SWITZERLAND 91/8794 - Atar S.A., Geneva 5500 Cover design: Gilbert Auberson * T M F N Symbols used in tables Preliminary, approximate or estimated data. Data not available. Nil or magnitude negligible. Category not applicable. Tata!. Male. Female. Absolute numbers. © World Health Organization 1991 The designations employed and the presentation of mate- rial in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation "country or area" appears in the headings of tables, it covers countries, territories, cities or areas. Signed articles express the opinions of the authors and do not necessarily represent the findings or policy of the World Health Organization. Couverture: Gilbert Auberson * T M F N Explication des signes Donnee preliminaire, approximative ou estimative. Donnee non disponible. Zero OU quantite negligeable. Categorie non applicable. Total. Masculin. Feminin. Nombres absolus. © Organisation mondiale de la Sante 1991 Les appellations employees dans cette publication et la presentation des donnees qui y figurent n'impliquent de la part du Secretariat de !'Organisation mondiale de la Sante aucune prise de position quant au statut juridique des pays, territoires, villes ou zones, ou de leurs autorites, ni quant au trace de leurs frontieres ou limites. Lorsque l'appellation «pays ou zone» apparait dans le titre des tableaux, elle couvre les pays, territoires, villes, ou zones. Les articles signes expriment les vues de leurs auteurs et ne correspondent pas necessairement aux conclusions ou a la politique adoptee par l'Organisation mondiale de ta Sante. WORLD HEAL TH STATISTICS QUARTERLY RAPPORT TRIMESTRIEL DE ST ATISTIQUES SANIT AIRES MONDIALES Vol. 44, No. 1, 1991 PROGRESS IN LEPROSY CONTROL THROUGH MULTIDRUG THERAPY CONTENTS Global review of multidrug therapy (MDT) in leprosy. S.K. Noordeen, L. Lopez Bravo & D. Daumerie ....... . Leprosy in the WHO African Region. D. Daumerie ..... . The national leprosy eradication programme in India. B.N. Mittal ................................... . Leprosy control in Zambia. G.J. Steenbergen ........ . Leprosy control activities of the International Federation of Anti-leprosy Associations. Dominique Martineau- Needham & Sarah Lacey ........................ . Page PROGRES DANS LA LUTTE ANTILEPREUSE PAR LA POL YCHIMIOTHERAPIE SOM MAIRE Polychimiotherapie (PCT) de la lepre dans le monde [resu- 2 me]. S.K. Noordeen, L. Lopez Bravo & D. Daumerie ..... . 16 La lepre dans la Region OMS de l'Afrique [resume]. D. Daumerie ................................. . Le programme national d'eradication de la lepre en lnde 23 [resume]. B. N. Mittal ........................... . 30 Lutte antilepreuse en Zambie [resume]. G. J. Steen- bergen ...................................... . Activites de lutte antilepreuse de la Federation interna- tionale des associations contre la lepre [resume]. 36 Dominique Martineau-Needham & Sarah Lacey ...... . Pages 15 22 29 35 45 -2- GLOBAL REVIEW OF MUL TIDRUG THERAPY (MDT) IN LEPROSY S. K. Noordeen, L. Lopez Bravo & D. Daumerie• It is well recognized that leprosy combines several problems which have serious implications for the individual, the family and the community. The chal- lenges posed by the disease include its communi- cability, its potential for causing physical de- formities, its chronicity, and its propensity to gener- ate intense negative social reaction. In addition, leprosy is a disease closely associated with socioeconomic underdevelopment, which means that where the disease exists there are impor- tant competing needs in other areas of health as well as in social services. Although information on the prevalence of leprosy is insufficient, it is estimated that there are about 10-12 million cases in the world. On the other hand, information on leprosy cases registered for treat- ment is much more reliable as it is based on actual records. There has been a very steady increase in the number of registered cases over 20 years: 2.8 million in 1966; 3.6 million in 1976; and 5.4 million in 1985. The latter figure represents an increase of 49% over 1976, and 90% over 1966. However, there has been a distinct change in the trend since 1985 with signifi- cant reduction in the number of registered cases. In this article, the latest available data on leprosy are presented at global, regional and country levels according to the following definitions: • Registered cases. Persons registered as leprosy cases with or without bacteriological confirmation of the diagnosis, and requiring chemotherapy. This definition excludes patients under surveil- lance or under care after specific chemotherapy. • Prevalence rate. This is the total number of leprosy cases per 10 OOO population according to the last midyear population data from World population prospects 1988.b • MDT coverage. Proportion of registered patients receiving regular or irregular MDT at the period indicated. MDT includes the regimens recom- mended by WHO or similar regimens. This indi- cator reflects the global progress of MDT implementation. • Completed MDT. Cumulative number of leprosy patients having completed the required treatment with MDT since the beginning of the programme. The figures available for 1987, 1988, 1989 and 1990 show distinct reductions in the number of registered cases. As compared with 5.4 million cases in 1985, 'Leprosy Unit, Division of Control of Tropical Diseases, World Health Organization, Geneva. O United Nations. World population prospects 1988. New York, United Nations, 1989. there were only 3.7 million cases in 1990 (a reduc- tion of about 31%). This is mainly attributed to MDT implementation and the resulting release from treatment of a significant number of patients. The distribution of leprosy in the world is shown in Map 1. The distribution of regis- tered cases, the prevalence rates and new cases detected, by WHO region as of 1990 (or for the most recent year for which information is available), are shown in Table 1 and Figs 1-3. Although only a proportion of estimated cases are ever registered for treatment, to a large extent the information on regis- tered cases reflects the leprosy situation in any given region and its relative importance vis-a-vis other regions. Information on registered cases by individual coun- tries/areas is given in the Annex. New case detection The information available on new cases is relatively less complete than for registered cases. The total number of new cases detected over 12 months in 1989-1990 is 576 361, indicating a global case- detection rate of 1.09 per 10 OOO population. The last column in Table 1 provides information on new cases detected. Progress with implementation of MDT The proportion of leprosy patients treated with MDT is shown in Table 2. MDT coverage has rapidly increased over the past few years, as shown in Table 3, and had reached 55.7% of the total regis- tered cases by October 1990. The relationship be- tween prevalence and MDT coverage in 1986-1990 is also shown in Figs 4 & 5. The increasing acceptability of MDT among national health services and leprosy patients themselves is due to: (i) the fixed, and relatively short duration, of MDT treatment; (ii) the low level of toxicity and treatment-related side-effects; (iii) the very low relapse rates following completion of treatment (0.10% per year for paucibacillary (PB) and 0.06% per year for multibacillary (MB) based on information from 85 125 PB cases and 22 087 MB cases; (iv) the significant reduction in frequency and severity of erythema nodosum leprosum (ENL) reactions. One more advantage of the WHO/MDT regimens is the considerable increase in the proportion of self- reporting cases at an early stage of the disease. Consequently, this has led to a reduction in the number and degree of deformities among new Rapp. trimest. statist. sanit. mond., 44 (1991) ~ Q. :,- s: "' .: ~· -0 c: "' ? J:: "' ~ // -;;:, 1111 ··., 1 . ..-,~;_ . ..,,./' Prevalence rate per 1 OOO (Number of countries/areas) Taux de prevalence pour 1000 (Nombre de pays/zones) D < 0.1 (109) ~ 0.1 - 0.9 (65) • 1 - 1.9 (19) ~ 2- 2.9 (06) • ;;,, 3 (03) f'fr't1, No data (02) t1ill Pas de donnees (02) MAP 1. PREVALENCE OF REGISTERED LEPROSY CASES IN THE WORLD AS AT 31 OCTOBER 1990 CARTE 1. PREVALENCE DES CAS DE LEPRE ENREGISTRES DANS LE MONDE AU 31 OCTOBRE 1990 I ;Ufn~ I --- !I C) \ \ .. 11111 -~ \_,~:Y J ~~-- \ \ \ \ -=- .) ~. i .... , . '/ • I II '.:t ,- .. , I \ :'. C< r,--+A w .. i:.> "' ~ 0 I 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 -4- FIG. 1 DISTRIBUTION OF LEPROSY CASES BY WHO REGION, 1990 REPARTITION DES CAS DE LEPRE PAR REGION OMS, 1990 Number of cases 482,669 301,704 2,693, 104 7,246 99,913 152,739 Afr ica Americas South-East Europe Afrique Ameriques Asia Asiedu Sud-Est WHO region - Region OMS Eastern Western Mediterranean Pacific Mediterranee Pacifique orientale occidental TABLE 1. DISTRIBUTION OF REGISTERED LEPROSY CASES, BY WHO REGION, 1990 TABLEAU 1. REPARTITION DES CAS DE LEPRE ENREGISTRES, PAR REGION OMS, 1990 WHO region Region OMS Africa - Afrique .. .... . . . Americas - Ameriques . ... . South-East Asia - Asie du Sud-Est Europe .. ............. . Eastern Mediterranean - Mediterranee orientale Western Pacific - Pacifique occidental World - Monde . . .. . ....... . Registe red cases Gas enregistres 482 669 301 704 2 693 104 7 246 99 913 152 739 3 737 375 Preva lence per10 OOO • Preva lence par 10 OOO• 9.20 4.20 20.50 0.10 2.60 1.00 7.10 Percentage New cases of total detected Pourcentage Cas nouveaux du total depistes 12.91 37 335 8.08 30 543 72.06 488 285 0.19 87 2.67 6 008 4.09 14 103 100.00 576 361 Case detection per 10 OOO • DE!pistage des cas par 10 OOO• 0.71 0.42 3.72 0.00 0.15 0.09 1.09 • Based on the 1990 midyear population data from I D'apres les donnees demographiques a la mi-1990 dans: United Nations. World population prospects 1988. New York, United Nations, 1989. TABLE 2. MULTIDRUG THERAPY (MDT) COVERAGE, BY WHO REGION, OCTOBER 1990 TABLEAU 2. COUVERTURE PAR LA POLYCHIMIOTHERAPIE (PCT), PAR REGION OMS, OCTOBRE 1990 Africa - Afrique .. .... . .. . . Americas - Ameriques ...... . South-East Asia - Asie du Sud-Est Europe ........ .... . . . . WHO region Reg ion OMS Eastern Mediterranean - Mediterranee orientale Western Pacific - Pacifique occidental World - Monde . . .......... . Registered cases Gas enregistr8s 482 669 301 704 2 693 104 7 246 99 913 152 739 3 737 375 Completed Coverage MDT Couverture PCT (% ) achevee 18.37 102 552 23.75 23 114 66.15 1 020 453 49.72 238 38.67 17 177 63.40 41 287 55.68 1 204 821 Rapp. trimest. statist. sanit. mond., 44 (1991) 20 15 10 5 0 -5- FIG.2 LEPROSY PREVALENCE RATES BY WHO REGION, 1990 TAUX DE PREVALENCE DE LA LEPRE PAR REGION OMS, 1990 Per 10 OOO Par 10 OOO Africa Afrique Americas AmE!riques South-East Europe Eastern Asia Mediterranean Asiedu ME!diterranee Sud-Est orienta le WHO region - Reg ion OMS Western World Pacific Pacifique Monde occidental TABLE 3. PROGRESS OF MULTIDRUG THERAPY (MDT) COVERAGE, 1986-1990 TABLEAU 3. EVOLUTION DE LA COUVERTURE PAR LA POLYCHIMIOTHERAPIE (PCT), 1986-1990 October October October October Octobre Octobre Octobre Octobre 1986 1987 1988 1989 Registered cases (thousands) - Cas enregistres (milliers) .... .... 5 341 5 078 4 908 3 866 Number of cases on MDT - Nombre de cas sous PCT . ... .. . . . 468 222 1 318 964 1 604 927 1 751 903 Percentage of total cases on MDT - Pourcentage du total des cas sous PCT 8.77 26 32.70 45.32 Number of cases completed MDT (cumulative total) - Nombre de cas ayant acheve une PCT (total general) ..... ...... ..... . . 93 216 515144 627 919 853 706 TABLE 4. LEVEL OF COVERAGE FOR MUL TIDRUG THERAPY (MDT) IN 93 LEPROSY ENDEMIC COUNTRIES, BY WHO REGION • TABLEAU 4. TAUX DE COUVERTURE DE LA POLYCHIMIOTHERAPIE (PCT) DANS 93 PAYS OU LA LEPRE EST ENDEMIQUE, PAR REGION OMS• South-East Eastern Western Coverage Africa Americas Asi a Mediterranean Pacific Couverture Afrique Ameriques Asiedu Europe Mediterranee Pacifique Sud-Est orientale occidental > 76% 8 12 4 0 3 12 51 - 75% 7 2 3 0 1 3 26 - 50% 4 4 2 0 0 2 11 -25% 8 1 0 0 3 1 1-10% 10 0 0 0 1 No information - Pas d'informations disponibles 1 0 0 0 1 Total .. .. ........ . . ....... .. . 38 19 9 0 9 18 October Octobre 1990 3 737 2 080 998 55.68 1 204 821 Total 39 16 12 13 11 2 93 a The countries were selected on the basis of a prevalence rate of a least 1 per 10 OOO population. Countrywide statistics are given in the Annex - Les pays ant Ste choisis sur la base d'un taux de prevalence d'au moins 1 malade pour 10 OOO habitants. Les statistiques detaillees des pays sont donnees dans !'annexe. Wld hfth statist. quart., 44119911 -6- FIG. 3 LEPROSY DETECTION BY WHO REGION, 1989 DEPISTAGE DE LA LEPRE PAR REGION OMS, 1989 Thousands - Milliers 600 500 400 300 200 100 0 - New cases Cas nouvea ux 37,335 30,543 Africa Americas Afrique Ameriques 488,285 87 6,008 14, 103 South-East Europe Eastern Western Asia Mediterranean Pacific Asiedu Mediterranee Pacifique Sud-Est orientale occidenta l WHO region - Region OMS FIG.4 GLOBAL LEPROSY PREVALENCE, MULTIDRUG THERAPY (MDT) COVERAGE AND NUMBER OF PATIENTS COMPLETING MDT, 1986-1990 PREVALENCE DE LA LEPRE DANS LE MONDE, COUVERTURE PAR LA POLYCHIMIOTHERAPIE (PCT) ET NOMBRE DE PATIENTS AVANT ACHEVE UNE PCT, 1986-1990 Millions 6 ~--------------------------~ 5 4 3 4-- Completed MDT - PCT achevee -+- MDT - PCT Prevalence - Prevalence 2 1 0 ~--------------------------~ 1986 1987 1988 1989 1990 Years - An nees Rapp. trimest. statist. sanit. mond., 44 (1991) -7- FIG. 5 GLOBAL LEPROSY PREVALENCE RATES AND MULTIDRUG THERAPY (MDT) COVERAGE, 1986-1990 TAUX DE PREVALENCE DE LA LEPRE DANS LE MONDE ET COUVERTURE PAR LA POLYCHIMIOTHERAPIE (PCT), 1986-1990 .,, Q) •Q) c 1986 1987 ~ 1988 .,, :;; Q) >- 1989 1990 10 5 Prevalence per 10 OOO Preva lence par 10 OOO FIG. 6 I - Preva lence - Preva lence B Coverage - Couverture - - - 0 25 50 MDT coverage (%1 Couvertu re par la PCT (% ) LEPROSY PREVALENCE AND MULTIDRUG THERAPY (MDT) COVERAGE, WHO AFRICAN REGION, 1986-1990 PREVALENCE DE LA LEPRE ET COUVERTURE PAR LA POLYCHIMIOTHERAPIE (PCTI. REGION OMS DE L'AFRIQUE, 1986-1990 1986 1987 .,, Q) •Q) c c <( I 1988 .,, "' Q) >- 1989 1990 20 15 10 Preva lence per 10 OOO Wld hlth statist. quart. , 44 (1991) Preva lence par 10 OOO 5 0 - Prevalence Prevalence ~ MDT coverage Couverture par la PCT 25 50 MDT coverage (%) Couverture par la PCT (%1 -8- FIG. 7 LEPROSY PREVALENCE AND MULTIDRUG THERAPY (MDT) COVERAGE, WHO REGION OF THE AMERICAS, 1986-1990 PREVALENCE DE LA LEPRE ET COUVERTURE PAR LA POLYCHIMIOTHERAPIE (PCT), REGION OMS DES AMERIQUES, 1986-1990 "' (1) ·(I) c c <( I "' :; (1) >- "' (1) ·(I) c c <( I "' :; (1) >- 1986 1987 1988 1989 1990 6 5 4 3 Prevalence per 10 OOO Prevalence par 10 OOO 2 1 FIG. 8 0 Prevalence Prevalence MDT coverage Couverture par la PCT 25 50 MDT coverage (%1 Couverture par la PCT (%1 LEPROSY PREVALENCE AND MULTIDRUG THERAPY (MDT) COVERAGE, WHO SOUTH-EAST ASIA REGION, 1986-1990 PREVALENCE DE LA LEPRE ET COUVERTURE PAR LA POLYCHIMIOTHERAPIE (PCT), REGION OMS DE L'ASIE DU SUD-EST, 1986-1990 1986 1987 1988 1989 1990 30 25 20 15 Prevalence per 10 OOO Prevalence par 10 OOO 10 5 0 - Prevalence Prevalence ~ MDT coverage Couverture par la PCT 25 50 MDT coverage (%1 Couverture par la PCT (%) Rapp. trimest. statist. sanit. mond., 44 (1991) "' " ,a, c c <( I "' :. " >- "' " ,a, c c <( I "' :. " >- -9- FIG. 9 LEPROSY PREVALENCE AND MULTIDRUG THERAPY (MDT) COVERAGE, WHO EASTERN MEDITERRANEAN REGION, 1986-1990 PREVALENCE DE LA LEPRE ET COUVERTURE PAR LA POL YCHIMIOTHERAPIE (PCT), REGION OMS DE LA MEDITERRANEE ORIENTALE, 1986-1990 1986 1987 1988 1989 1990 3 2 Prevalence per 10 OOO Preva lence pa r 10 OOO 1 0 FIG. 10 - Preva lenCe Preva lence ~ MDT coverage Couvertu re pa r la PCT 25 50 M DT coverage (%) Couve rtu re par la PCT (%) LEPROSY PREVALENCE AND MUL TIDRUG THERAPY (MDT) COVERAGE, WHO WESTERN PACIFIC REGION, 1986-1990 PREVALENCE DE LA LEPRE ET COUVERTURE PAR LA POL YCHIMIOTHERAPIE (PCT), REGION OMS DU PACIFIQUE OCCIDENTAL, 1986-1990 1986 1987 1988 1989 1990 3 2 Preva lence per 10 OOO Preva lence par 10 OOO 1 0 - Preva lence Preva lence ~ MDT coverage Couve rture par la PCT 25 50 75 MDT coverage (%) Couve rture par la PCT (%) W ld hlth statis t. quart., 44 (1991) - 10 - cases; an increased acceptance and compliance of patients to treatment; and better community support to patients. Figs 5-10 show the impact of MDT implementation at the global and WHO regional levels for the years 1986-1990, for which more accurate and reliable data were available. There are considerable regional vari- ations with regard to changes in prevalence as well as MDT coverage from 1986 to 1990. MDT coverage is showing satisfactory progress in two regions (South-East Asia and Western Pacific) while this is not the case with other regions. Even within WHO regions there are variations among countries with regard to MDT coverage (Table 4). 39 leprosy- endemic countries (42%) have 76% or more of their registered leprosy patients on MDT, and 55 coun- tries (59%) have more than 50% MDT coverage of their patients. Box 1 provides a summary overview of positive experiences with MDT to date and of problems encountered, both on the technical and on the operational/administrative side. Future prospects With increasing political commitment in many coun- tries to deal with leprosy effectively, with the increa- sing appreciation of the value of multidrug therapy as a very potent technology, and with increasing international cooperation, both from the bilateral and multilateral sectors enabling additional inputs, it is not unrealistic to expect a reduction of the leprosy case load by as much as 60-80% in the next 5-7 years, at least in countries with effective pro- grammes. However, notwithstanding anticipated major reductions in prevalence, it should be rec- ognized that other problems will remain for a long time to come, such as disabilities after patients have been cured for several years and a continued, albeit reduced, incidence of new disease arising from in- fections caught several years earlier. Hence, apart from investing heavily in efforts to reduce leprosy prevalence through MDT, there is a need to plan for the future so that leprosy control becomes part and parcel of primary health care, encompassing early detection and treatment as well as disability preven- tion and management. Conclusions There is no doubt that MDT has brought about a major change in technology for leprosy control. It has also resulted in a new outlook towards the disease, and raised hopes among patients, health workers, and programme managers alike. Where the implementation of MDT is vigorous and sustained, the results are extremely gratifying. Problems, both technical and operational, need to be constantly reviewed and solutions found. The opportunities to markedly reduce leprosy in the next decade are immense. It remains to be seen whether or not we make use of them, and whether or not leprosy will ultimately be eliminated as a public health problem. Box 1. Positive experiences and problems with MDT POSITIVE EXPERIENCES Technical Low frequency of drug toxicity in the field High level of acceptance of clofazimine discolor- ation Patient satisfaction of clinical response Significant reduction in frequency and severity of ENL reactions Very low relapse rates after cessation of treatment Operational/administrative Marked increase in treatment compliance by patients Increase in detection of new cases through volun- tary reporting Better motivation among health workers Greater community support resulting from the recognition of MDT as effective technology Higher priority for leprosy control PROBLEMS Technical Difficulties in classifying a proportion of patients, partly as a result of inadequate laboratory services Disappointment with the slow decrease of the bac- teriological index (BI) Slow clinical response following the initial period of very satisfactory response Difficulties in distinguishing between relapse and late reversal reactions in PB leprosy Lack of any impact on the deformity situation Operational/administrative Inability to increase the priority for leprosy in some countries as a result of other pressing health needs Poor health infrastructure to cope with MDT Inadequate resources, particularly for drugs Absence of a proper plan of action to implement MDT Inadequate training of health workers Lack of laboratory facilities for reliable skin-smear examinations Poor referral facilities to deal with complications Insufficient patient education on what to expect from MDT so that when the time comes for stop- ping treatment, the patient will be willing to accept the decision Rapp. trimest. statist. sanit. mond., 44 (1991) - 11 - ANNEX - ANNEXE Table i. Registered leprosy cases and cases on multidrug therapy (MDT), WHO African Region Tableau i. Cas de lepre enregistres et cas sous polychimiotherapie (PCT), Region OMS de l'Afrique Algeria - Algerie Angola ..... Benin - Benin . Botswana .. Burkina Faso .. Countries/areas Pays/zones Burundi ..... Cameroon - Cameroun Cape Verde - Cap-Vert . Central African Republic - Republiquecentrafricaine Chad - Tchad .... Comoros - Comores Congo ....... . Cote d'Ivoire .... . Equatorial Guinea - Guinee equatoriale Ethiopia - Ethiopie Gabon ...... . Gambia - Gambie Ghana ...... . Guinea - Guinee Guinea Bissau - Guinee-Bissau Kenya ...... . Lesotho ..... . Liberia - Liberia Madagascar .. . Malawi ..... . Mali ....... . Mauritania - Mauritanie Mauritius - Maurice Mozambique ..... Namibia - Namibie . Niger ........ . Nigeria - Nigeria .. Reunion - Reunion . Rwanda ....... . Sao Tome and Principe - Sao Tome-et-Principe . Senegal - Senegal ...... . Seychelles ........... . Sierra Leone . . . . . . . . . . . South Africa - Afrique du Sud Swaziland ..... . Togo .............. . Uganda - Ouganda ...... . United Republic of Tanzania - Republique-Unie de Tanzanie .. . Zaire - Za"ire .. . Zambia - Zambie . Zimbabwe ..... Whole region - Ensemble de la region . Year a Annee a 1985 1988 1989 1989 1988 1989 1988 1989 1988 1988 1987 1989 1988 1987 1988 1988 1988 1989 1988 1988 1988 1988 1988 1988 1989 1988 1987 1988 1988 1989 1988 1988 1987 1988 1987 1988 1987 1989 1988 1988 1988 1990 1989 1989 1988 1989 Registered cases Cas enregistres 18 4 046 5655 100 13 312 75 12 302 491 7 096 10 651 83 6 416 24 291 47 31 753 2 491 440 7 773 15 818 1 179 3198 188 4589 19 210 1 895 22 121 1 343 26 24338 26 6 277 193 715 155 1 065 4 11 554 41 1 680 962 338 3 987 15 OOO 5840 13 242 7 469 369 482 669 Prevalence per 10 OOO' Prevalence par 10 OOO' 0.01 4.00 11.90 0.80 14.80 0.10 10.90 12.90 24.40 18.80 1.60 32.20 19.30 1.10 6.80 21.30 5.10 5.20 23.00 11.90 1.30 1.10 18.00 16.00 2.20 23.60 6.60 0.20 15.50 0.10 8.80 17.10 2.60 1.50 0.40 15.70 5.90 4.00 0.30 4.30 11.50 8.10 2.10 3.70 8.80 0.40 9.20 a Last year for which data are available - Derni0re an nee pour laquelle des donnees sont disponibles. Cases on MDT Cas sousPCT 10 3 410 1 152 100 1 063 75 4338 13 2 086 675 83 247 2 310 43 17 144 1 291 440 4 757 2 247 1 179 2 326 110 1 773 2 307 1 895 731 26 1 561 415 8 250 28 183 0 1 453 19 1 103 506 42 187 2 591 5 296 8 799 6 095 324 88683 MOT coverage Couverture par la PCT (%) 55.60 84.30 20.40 100.00 8.00 100.00 35.30 2.60 29.40 6.30 100.00 3.80 9.50 91.50 54.00 51.80 100.00 61.20 14.20 100.00 72.70 58.50 38.60 12.00 100.00 3.30 100.00 6.40 6.60 4.30 18.10 17.20 0.00 12.60 46.30 65.70 52.60 12.40 4.70 17.30 90.70 66.40 81.60 87.80 18.40 Completed MDT PCT achevee 42 1165 1 626 2 759 1 649 892 1 032 441 4 778 29 272 1 694 8 217 862 111 1 179 259 444 3 598 12 397 530 52 114 771 2 251 96 337 0 614 22 5 559 416 241 176 11 146 6 OOO 2 809 102 552 ' Based on the 1990 midyear population data from I D'apres les donnees demographiques a la mi-1990 dans: United Nations. World population prospects 1988. New York, United Nations, 1989. Wld hlth statist. quart., 44 (1991) - 12 - Table ii. Registered leprosy cases and cases on multidrug therapy (MDT), WHO Region of the Americas Tableau ii. Cas de 16pre enregistr6s et cas sous polychimioth6rapie (PCT), R6gion OMS des Am6riques Countries/areas Pays/zones Anguilla ................... . Antigua and Barbuda - Antigua-et-Barbuda Argentina - Argentine Bahamas ...... . Barbados-Barbades Belize ......... . Bermuda - Bermudes Bolivia - Bolivie Brazil - Brasil Canada ..... . Chile - Chili .. . Colombia - Colombia Costa Rica ...... . Cuba ......... . Dominica - Dominique . Dominican Republic - Republique dominicaine Ecuador - Equateur . . . . . . . . El Salvador ............. . French Guiana - Guyane fran~aise Grenada - Grenade Guadeloupe Guatemala Guyana ... Haiti - Ha"iti Honduras .. Jamaica - Jama"ique Martinique ..... Mexico - Mexique Montserrat Nicaragua .. Panama ... . Paraguay .. . Peru - Perou Saint Lucia - Sainte-Lucie Saint Vincent and the Grenadines - Saint-Vincent- et-Grenadines .............. . Suriname ...................... . Trinidad and Tobago - Trinite-et-Tobago ... . Turks and Caicos Islands - lies Turques et Cai'ques United States of America - Etats-Unis d'Amerique Uruguay Venezuela ................ . Whole region - Ensemble de la region . Year• Annee a 1989 1986 1989 1985 1989 1988 1987 1988 1988 1987 1987 1988 1990 1990 1989 1989 1988 1987 1988 1987 1988 1990 1988 1985 1990 1989 1989 1989 1989 1985 1990 1989 1988 1989 1989 1989 1989 1989 1989 1987 1989 Registered cases Cas enregistres 8 9809 41 2 0 1 1 648 239 862 168 18 8 973 401 4185 2 1 098 1 047 6 58 8 323 272 120 558 101 20 296 16 778 142 136 3 056 1 604 57 4 285 80 2 6098 279 4158 301 704 Prevalence per 10 OOO• Prevalence par 10 OOO• 0.90 3.00 1.60 0.10 0.00 0.20 2.30 16.00 0.10 0.01 2.80 1.30 4.10 0.20 1.50 1.00 0.01 6.30 0.80 9.50 0.30 1.20 0.90 0.20 0.10 8.90 1.90 0.40 0.60 7.10 0.70 4.20 0.40 7.10 0.60 2.20 0.20 0.90 2.10 4.20 • Last year for which data are available - Derniere annee pour laquelle des donnt!es sont disponibles. Cases on MDT Cas sousPCT 8 6119 41 2 0 1 839 31 416 9 7 229 132 4105 2 1 085 1 047 5 58 4 133 120 532 82 20 92 7476 102 2694 409 57 4 285 76 2 3953 238 3 277 71 654 MDT coverage Couverture par la PCT (%) 100.00 62.40 100.00 100.00 100.00 50.90 13.10 50.00 80.60 32.90 98.10 100.00 98.80 100.00 83.30 100.00 50.00 41.20 100.00 95.30 81.20 100.00 31.10 44.60 75.00 88.20 25.50 100.00 100.00 100.00 95.00 100.00 64.80 85.30 78.80 23.75 Completed MDT PCT achevee 4 37 1 749 31 6682 0 1 688 1 672 22 2184 597 0 159 23 665 524 155 97 165 2 34 2 505 215 181 53 326 792 10 351 2 179 23114 • Based on the 1990 midyear population data from I D'aprlos les donnt!es demographiques a la mi-1990 dans: United Nations. World population prospects 1988. New York, United Nations, 1989. Table iii. Registered leprosy cases and cases on multidrug therapy (MDT), WHO South-East Asia Region Tableau iii. Cas de 16pre enregistr6s et cas sous polychimioth6rapie (PCT), R6gion OMS de I' Asia du Sud-Est Registered Prevalence Cases on MDT Completed Countries/areas Year• cases per 10 OOO• MDT coverage MDT Pays/zones Annee • Cas Prevalence Cas Couverture PCT enregistres par 10 OOO• sousPCT parlaPCT achevt!e (%) Bangladesh 1989 21 191 1.80 11 387 53.70 13 658 Bhutan - Bhoutan 1989 399 2.60 356 89.20 2 336 India - lnde . . . . 1990 2 370 687 27.70 1 623 OOO 68.50 911 OOO Indonesia - Indonesia 1988 121 512 6.70 31 664 26.10 14 768 Maldives .... 1989 388 18.00 297 76.50 590 Myanmar ........ 1989 134 487 32.30 86902 64.60 29 935 Nepal - Nepal . . . . . 1989 25 361 13.20 11 938 47.10 13 307 Sri Lanka ........ 1989 2 416 1.40 2 343 97.00 10 609 Thailand - Tharlande . 1989 16 663 3.00 13 695 82.20 24250 Whole region - Ensemble de la region . 2 693104 20.50 1 781 582 66.20 1020453 • Last year for which data are available - Derniere annee pour laquelle des donnees sont disponibles. • Based on the 1990 midyear population data from I D'aprlos les donnees demographiques a la mi-1990 dans: United Nations. World population prospects 1988. New York, United Nations, 1989. Rapp. trimest. statist. sanit. mond., 44 (1991) - 13 - Table iv. Registered leprosy cases and cases on multidrug therapy (MDT), WHO European Region Tableau iv. Cas de 1,pre enregistr6s et cas sous polychimioth6rapie (PCT), R6gion OMS de l'Europe Countries/areas Pays/zones Albania - Albanie .. Austria - Autriche Belgium - Belgique Bulgaria - Bulgarie . Czechoslovakia - Tchecoslovaquie Denmark - Danemark Finland - Finlande ........ . France ............... . German Democratic Republic c - Republique democratique allemande c • • • • • • • • • • • • Germany, Federal Republic of c - Republique federale d'Allemagne c Greece - G rece . . Hungary - Hongrie Iceland - lslande Ireland - lrlande Israel - Israel Italy - ltalie Luxembourg . Malta - Malte Monaco .... Netherlands - Pays-Bas Norway - Norvege Poland - Pologne .. . Portugal ....... . Romania - Roumanie Spain - Espagne .. Sweden - Suede . . Switzerland - Suisse Turkey - Turquie .. United Kingdom - Royaume-Uni USSR - URSS ...... . Yugoslavia - Yougoslavie . . . . Whole region - Ensemble de la region Year• Annee • 1987 1990 1989 1989 1989 1980 1989 1989 1989 1990 1989 1989 1989 1989 1988 1989 Registered cases Cas enregistres 2 3 3 19 203 540 0 5 8 117 55 1 3466 135 2 689 0 7 246 Prevalence per 10 OOO• Prevalence par 10 OOO• 0.01 0.00 0.00 0.02 0.40 0.10 0.00 0.10 0.01 0.10 0.02 0.00 0.60 0.02 0.10 0.00 0.10 • Last year for which data are available - Oerniere an nee pour laquelle des donnees sont disponibles. Cases on MOT Cas sousPCT 2 3 3 19 63 5 117 52 579 70 2 689 3 603 MDT coverage Couverture par la PCT (%) 100.00 100.00 100.00 100.00 31.00 100.00 100.00 94.50 100.00 16.70 51.90 100.00 49.7 Completed MOT PCT achevee 6 176 55 238 • Based on the 1990 midyear population data from I o•apres les donnees demographiques a la mi-1990 dans: United Nations. World population prospects 1988. New York, United Nations, 1989. ' As at 3 October 1990, the German Democratic Republic and the Federal Republic of Germany united to form one sovereign State called the "Federal Republic of Germany" - A dater du 3 octobre 1990, la Republique democratique allemande et la Republique federale d'Allemagne se sont unies pour former un Etat souverain denomme « Republique federale d' Allemagne ... Wld hlth statist. quart., 44 (1991) - 14 - Table v. Registered leprosy cases and cases on multidrug therapy (MDT), WHO Eastern Mediterranean Region Tableau v. Cas de llpre enregistres et cas sous polychimiotherapie (PCT), Region OMS de la Mediterranee orientale Registered Prevalence Countries/areas Year a cases per 10 OOO b Pays/zones Annee a Cas Prevalence enregistres par10 OOO b Afghanistan . . . . 1989 1 704 1.00 Bahrain - Bahrei'n 1989 36 0.70 Cyprus - Chypre 1988 102 1.50 Djibouti ....... 1989 35 0.90 Egypt - Egypte . . 1989 10 196 1.90 Iran, Islamic Republic of - Republique islamique d'lran ....... 1989 13 664 2.40 Iraq ......... 1989 36 0.02 Jordan - Jordanie 1989 20 0.05 Kuwait - Kowei't 1985 0 0.00 Lebanon - Liban 1984 45 0.20 Libyan Arab Jamahiriya - Jamahiriya arabe libyenne 1989 205 0.50 Morocco - Maroc . 1989 5 972 2.40 Oman .. 1989 651 4.40 Pakistan ...... 1988 10 775 0.90 Qatar .. . . . . . . 1989 1 0.03 Saudi Arabia - Arabie saoudite 1987 175 0.10 Somalia - Somalie ....... 1989 1 084 1.40 Sudan - Soudan ........ 1988 51 716 20.50 Syrian Arab Republic - Republique arabe syrienne 1988 146 0.10 Tunisia - Tunisie ................ 1987 145 0.20 United Arab Emirates - Emirats arabes unis . 1989 22 0.10 Yemen c - Yemen c •••••••.••• 1989 3183 3.00 Whole region - Ensemble de la region 99 913 2.60 a Last year for which data are available - Derniere an nee pour laquelle des donnees sont disponibles. Cases on MDT Cas sousPCT 250 1 35 10.196 13 664 36 0 205 224 91 3463 1 717 6450 146 145 22 2 986 38 632 MDT coverage Couverture par la PCT (%) 14.70 2.80 100.00 100.00 100.00 100.00 0.00 100.00 3.80 14.00 32.10 100.00 66.10 12.50 100.00 100.00 100.00 93.80 38.70 Completed MDT PCT achevee 6400 593 1 013 494 6174 1 069 870 413 1 150 17 177 b Based on the 1990 midyear population data from I D'apres les donnees demographiques a la mi-1990 dans: United Nations. World population prospects 1988. New York, United Nations, 1989. , As of 22 May 1990, the Yemen Arab Republic and the People's Democratic Republic of Yemen merged to form a single sovereign State called the "Republic of Yemen". The figures given here do not include the former People's Democratic Republic of Yemen - A dater du 22 mai 1990, la Republique arabe du Yemen et la Republique dBmocratique populaire du Yemen se sont unies pour former un Etat souverain unique denomme 11Republique du Yemen)), Les chiffres ci-dessus n'incluent pas l'ex-Republique democratique populaire du Yemen. Rapp. trimest. statist. sanit. mond., 44 (1991) - 15 - Table vi. Registered leprosy cases and cases on multidrug therapy (MDT), WHO Western Pacific Region Tableau vi. Cas de litpre enregistnis et cas sous polychimioth,rapie (PCT), R,gion OMS du Pacifique occidental Countries/areas Pays/zones Year• Annee a Registered cases Prevalence per 10 OOO' Prevalence par 10 OOO' Cases on MDT MDT coverage Completed MDT Cas enregistres Cas sousPCT Couverture par la PCT PCT achevee American Samoa - Samoa americaines Australia - Australie . . . . . . . . . . . . Brunei Darussalam - Brunei Darussalam . Cambodia - Cambodge China - Chine .............. . Cook Islands - lies Cook . . . . . . . . . Fiji - Fidji ................ . French Polynesia - Polynesie frani;aise . Guam ..... . Hong Kong ................ . Japan - Japon ............. . Kiribati .................. . Lao People's Democratic Republic - Republique democratique populaire lao .... . Macao ................. . Malaysia - Malaisie ............... . New Caledonia - Nouvelle-Caledonie ..... . New Zealand - Nouvelle-Zelande ........ . Pacific Islands Trust Territories - Territoires sous tutelle des lies du Pacifique . . . . . . . . . . . Papua New Guinea - Papouasie-Nouvelle-Guinee Philippines ................. . Republic of Korea - Republique de Coree Samoa .............. . Singapore - Singapour .... . Solomon Islands - lies Salomon Tonga .. Tuvalu Vanuatu ............. . Viet Nam ............. . Whole region - Ensemble de la region . 1990 1990 1990 1990 1990 1989 1990 1990 1989 1990 1988 1988 1988 1990 1990 1990 1990 1990 1990 1989 1990 1990 1990 1990 1990 1990 1990 1988 62 166 3 1 618 55 240 0 175 42 35 101 768 72 3 019 96 5 221 75 66 707 6 345 37 870 2 OOO 25 481 317 0 0 16 38 219 152 739 16.20 0.10 0.10 2.00 0.50 0.00 2.30 2.30 2.90 0.20 0.10 10.50 7.40 2.00 3.00 4.50 0.20 40.90 15.80 6.10 0.50 1.50 1.80 9.60 0.00 0.00 1.00 5.70 1.00 62 20 3 1 250 45 058 175 42 35 101 768 72 1 773 96 1 554 65 66 707 1 514 26250 2 OOO 25 481 191 16 14 520 96 844 (%) 100.00 12.00 100.00 77.30 81.60 100.00 100.00 100.00 100.00 100.00 100.00 58.70 100.00 29.80 86.70 100.00 100.00 23.90 69.30 100.00 100.00 100.00 60.30 100.00 38.00 63.40 7 9 15 245 15 189 137 0 359 0 2 019 82 591 296 66 698 672 4143 2 494 182 289 118 9 8 145 13 514 41 287 • Last year for which data are available - Derniere annee pour laquelle des donnees sont disponibles. ' Based on the 1990 midyear population data from I D'apres les donnees demographiques a la mi-1990 dans: United Nations. World population prospects 7988. New York, United Nations, 1989. SUMMARY Leprosy continues to be an important public health problem in most countries of Asia, Africa and Latin America. While there has been a steady increase in the number of registered leprosy cases from 1966 to 1985, since then there has been a substantial reduc- tion of over 30% in the number of registered cases. This is mainly attributed to the introduction of multi- drug therapy (MDT) as recommended by a WHO study group on chemotherapy of leprosy for control programmes in 1981. The coverage for MDT has steadily increased over the last 5 years, reaching a global figure of 55.7% of all registered cases by October 1990. Over 2 million leprosy patients are currently undergoing MDT and, in addition, over 1 million patients have completed MDT since 1985. MDT has been found to be generally well tolerated with a high level of acceptability leading to improv- ed treatment compliance. MDT coverage shows wide variations among WHO regions and among indi- vidual countries. The prospects for further re- ductions in prevalence of registered cases in the next decade are very bright. However, problems such as early case detection, and prevention and management of disabilities after patients have been cured for several years, will continue to pose signifi- cant challenges. RESUME Polychimiotherapie (PCT) de la lepre dans le monde La lepre reste un important probleme de sante publi- que dans la plupart des pays d'Asie, d'Afrique et d'Amerique latine. Si le nombre des cas de lepre enregistres a augmente regulierement entre 1966 et 1985, ii a baisse de plus de 30% depuis. Ce recul est du surtout a !'introduction de la polychimiotherapie (PCT) telle que l'a recommandee en 1981 le Groupe d'etude OMS sur la chimiotherapie de la lepre pour les programmes de lutte. La PCT a ete etendue progressivement au cours de ces 5 dernieres annees; en octobre 1990, la couverture mondiale etait de 55,7% de tous les cas enregistres. Plus de 2 millions de lepreux sont actuellement sous PCT et Wld hlth statist. quart., 44 ( 1991) plus d'un million de malades ant en outre acheve une PCT depuis 1985. Generalement bien tolere et parfaitement accepte, le traitement est suivi de far;:on plus reguliere. La couverture par la PCT varie sensi- blement selon les regions de l'OMS et selon les pays. II y a tout lieu de penser que la prevalence des cas enregistres au cours de ces 10 prochaines annees diminuera encore. Toutefois, le depistage precoce ainsi que la prevention et la prise en charge des invalidites chez les malades gueris depuis plu- sieurs annees continueront de poser de serieux pro- blemes. - 16 - LEPROSY IN THE WHO AFRICAN REGIONa D. Daumerieb The prevalence of leprosy in the WHO African Region is the second highest in the world, with 0.92 per 1 OOO. The total number of registered cases in this region (482 669) represents 13% of the world total. In the 1960s, leprosy control was based on vertical programmes and mass treatment with sul- fones. The need to use multidrug therapy (MDT) because of the emergence of dapsone resistance, and the integration of health-service activities ac- cording to the primary health care approach, have modified strategies for leprosy control. All countries of the region have adopted MDT as their official treatment strategy, but they sometimes encounter difficulties in implementing it. The inter- regional conference on leprosy control in Africa held in Brazzaville in November 1989 has provided much information to review the current situation and to see what progress has been made in implementing MDT in Africa: how to overcome the difficulties, if any, of implementing MDT within primary health care (PHC); how to control leprosy through MDT under varying conditions; how to build national capabilities; and how to identify ways of coordinat- ing leprosy control through MDT with the participat- ing funding agencies. Leprosy situation and MDT progress Situation analysis The distribution of leprosy cases is uneven among the countries of the region, and even within indi- vidual countries. At the end of 1990, out of a popula- tion of about 500 million, 482 669 patients were registered for treatment, representing a global preva- lence rate of about 1 case per 1 OOO population and a detection rate of 8 per 100 000. About 40% of patients in the African Region are found in Nigeria alone. Available data on the distribution of patients according to age, sex or type of leprosy are very limited. The results of some surveys and pro- grammes, however, provide the following informa- tion: • proportion of children <15 among new cases-9%; • proportion of multibacillary (MB) patients among new cases-5-20%; • proportion of patients with physical disabilities among new cases-10%; • proportion of patients with physical disabilities among total registered cases-25-40%. The distribution by country of leprosy cases in the WHO African Region, and the proportion of registe- red cases treated with MDT, are given in Annex •This article is based on a presentation made at the WHO interregional conference on leprosy control in Africa, Brazzaville, 6-10 November 1989. O Leprosy Unit, World Health Organization, Geneva. table i, p. 11. Fig. 1 shows MDT coverage by sub- region. Leprosy control All countries of the region have reoriented their strategies and introduced MDT, but less than 20% of the known patients are being treated with MDT, and coverage varies considerably from country to country. About 103 OOO patients had completed treat- ment up to 1989. Subregion I, which comprises 18 countries situated in the north-west and west, has a prevalence rate that is twice as high as that of other subregions, with a total of about 320 OOO patients. The prevalence of the disease has, however, de- clined considerably over the past 20 years. This drop can be explained by various factors such as ef- fectiveness of programmes based on dapsone; high population increase; decline in the incidence of the disease; updating of available data; reduction in detection activities. Leprosy control has normally been carried out by specialized staff. But special efforts are now being made for patients to be treated with MDT in general health units. A number of obstacles still remain in moving from a vertical specialized system to an integrated one; these probably explain the low MDT coverage in the subregion. Subregion II, which comprises 13 countries situated in the centre and east, has for a long time been considered as a very high prevalence area. Preval- ence has declined considerably in recent years, to reach the present level of about 0.7 per 1 OOO. Most of the programmes are based on vertical structures and the introduction of MDT is progressing very slowly, except in Ethiopia. In Subregion Ill, which comprises 16 countries situ- ated in the southern part of the continent, the lep- rosy problem has declined considerably in recent years. The general MDT coverage of Subregion Ill is higher than that of the other subregions. Classification of countries according to the current leprosy situation In order to set targets, it would be useful to classify the countries according to leprosy endemicity and leprosy control (Box 1). In this way, guidelines to enable countries to progress from one level to the next can be more readily prepared. However, there are many biases in such a classification: the total number of registered cases could be far from the number of estimated cases; MDT coverage is a global indicator which does not take into account the performance of detection or treatment activities. Rapp. trimest. statist. sanit. mond., 44 11991) - 17 - FIG. 1 MULTIDRUG THERAPY (MDT) COVERAGE, WHO AFRICAN REGION, 1989 COUVERTURE PAR LA POLYCHIMIOTHERAPIE (PCTI. REGION OMS DE L'AFRIQUE, 1989 350 300 U) "' (.) ~ 250 Q) .0 E ~ 200 I U) Q) U) 150 "' (.) 0 oi ..c 100 E :::, z 50 0 Thousands Milliers Subregion I Sous-region 1111 Cases on MDT Cas sous PCT Level I. The prevalence of leprosy is very low (<1 per 10 OOO), and very few new cases are diagnosed annually (<1 per 100 OOO). Leprosy is not a public health problem. Newly-detected cases are managed by the general health services and all existing cases receive MDT. Level /IA. The prevalence of leprosy is medium, from 1 per 10 OOO to 10 per 10 OOO. Nationwide MDT coverage is more than 75% of registered cases and prevalence has declined over the past 5 years. Level //B. The prevalence of leprosy is medium, from Subregion II Sous-region II D Registered cases Cas enregistres Subregion Ill Sous-region Ill 1 per 10 OOO to 10 per 10 OOO. Nationwide MDT coverage is less than 75% of registered cases and prevalence has not declined over the past 5 years. Level I/IA. Leprosy remains a major public health problem with a prevalence rate >10 per 10 OOO but MDT has been introduced and covers at least one- third of existing and new cases. Level 1118. Leprosy is a serious public health problem with a prevalence rate of >10 per 10 OOO and MDT has been partly implemented, or covers less than one-third of new and existing cases. Box 1. Classification of countries according to endemicity level and multidrug therapy (MDT) coverage, WHO African Region Level I Level !IA Level 118 Level IIIA Level 1118 Low endemicity/ Medium endemicity/ Medium endemicity/ High endemicity/ High endemicity/ High MDT coverage MDT coverage >75% MDT coverage ,,;;; 75% MDT coverage >33% MDT coverage ,,s, 33% Algeria Angola Ethiopia Cameroon Benin Botswana Comoros Ghana Gabon Burkina Faso Burundi Equatorial Guinea Kenya Guinea Bissau Cape Verde Mauritius Gambia Lesotho Madagascar Central African Rep. Namibia Malawi Mauritania Chad South Africa United Rep. of Tanzania Niger Congo Zimbabwe Zambia Reunion Cote d'Ivoire Rwanda Guinea Seychelles Mali Sierra Leone Mozambique Swaziland Nigeria Uganda Senegal Zaire Togo Wld hlth statist. quart., 44 (1991) - 18 - Leprosy situation in African countries by level of endemicity Level I In these countries, leprosy prevalence is close to zero, and leprosy patients are treated with MDT by the general health services. The goal of leprosy control is to eliminate leprosy. The main objectives are: to integrate leprosy control into general health services; to diagnose new cases early; to maintain health personnel awareness of leprosy; and to diag- nose relapses. Algeria 18 cases Prevalence rate: 0.01 per 10 OOO MDT coverage: 55.6% Leprosy is not a public health problem in Algeria. Patients are treated with MDT in hospitals and der- matology clinics. Botswana 100 cases - 65 MB; 35 PBc Prevalence rate: 8 per 10 OOO Detection rate: 0.1 per 10 OOO MDT coverage: 100% Leprosy is not a major public health problem and all registered and new cases are treated with MDT. Leprosy control (including case detection) has to be continued in order to ensure that prevalence con- tinues to decline. Burundi 75 cases - 75 MB Prevalence rate: 0.10 per 10 OOO Detection rate: 0.21 per 10 OOO MDT coverage: 100% Since 1976, the leprosy control programme is in- tegrated into the general health structure. Four mobile teams are responsible for the supervision of activities. At the national level, the programme has been combined with tuberculosis control since 1984. MDT was introduced in the country in 1981, and the regimens used are different from those recom- mended by WHO. The short duration of the regimen used, especially for MB patients, could explain that the detection rate is higher than the prevalence rate. However, low endemicity in this area and efficacy of regimen have to be confirmed by further studies. Mauritius Namibia South Africa Zimbabwe 26 cases Prevalence rate: 0.20 per 10 OOO Detection rate: 0.03 per 10 OOO MDT coverage: 100% 26 cases Prevalence rate: 0.10 per 10 OOO Detection rate: 0.17 per 10 OOO MDT coverage: unknown 962 cases Prevalence rate: 0.30 per 10 OOO Detection rate: 0.04 per 10 OOO MDT coverage: 52.6% 369 cases Prevalence rate: 0.40 per 10 OOO Detection rate: 0.14 per 10 OOO MDT coverage: 87.8% The leprosy control programme has been es- tablished since 1983, and is now in the process of 'MB: multibacillary; PB: paucibacillary; NK: classification not specific. integration within the general health structure. In- tegration has become a priority because of the rapid decrease in prevalence. Level /IA Level IIA includes countries where leprosy endem- icity is medium and leprosy control provides MDT to more than 75% of known patients. In these countries, the goal is to reduce within 5 years the endemicity level of the disease by treat- ing all known cases with MDT. The main objectives are: to extend MDT coverage; to improve early case finding; and to prepare integration of leprosy control where leprosy control is specialized. Angola 4 046 cases - 2 429 PB; 1 478 MB; 109 NKC Prevalence rate: 4 per 10 OOO Detection rate: 0.3 per 10 OOO MDT coverage: 84.3% The country is divided into 18 provinces and leprosy control is combined with tuberculosis control. MDT was introduced in 1987. Comoros 83 cases - 25 PB; 58 MB Prevalence rate: 1.6 per 10 OOO Detection rate: 2.1 per 10 OOO MDT coverage: 84.3% Equatorial Guinea 47 cases Prevalence rate: 1.1 per 10 OOO Detection rate: 0.8 per 10 OOO MDT coverage: 91.5% Gambia 440 cases - 117 PB; 323 MB Prevalence rate: 5.1 per 10 OOO Detection rate: 0.3 per 10 OOO MDT coverage: 100% The leprosy control programme is combined with the tuberculosis programme at the national, regional and district levels, but is integrated into PHC at the peripheral level. MDT was introduced in 1984 and since the start of the programme, prevalence has shown a sharp decline. Malawi 1 895 cases - 662 PB; 1 233 MB Prevalence rate: 2.2 per 10 OOO Detection rate: 1.2 per 10 OOO MDT coverage: 100% The country is divided into 24 districts. The leprosy control programme is fully vertical, with at least one leprosy worker per district. MDT was introduced in 1983, and because of the dramatic decline in preva- lence, the country has decided to combine leprosy with a skin-disease programme. United Republic of Tanzania 5 840 cases Prevalence rate: 2.1 per 10 OOO Detection rate: 1.4 per 10 OOO MDT coverage: 90.7% The country is divided into 25 regions with 3-7 districts each. The leprosy control programme is combined with tuberculosis control, both fully in- tegrated into the PHC structure. MDT was introduced in 1982 and the regimens used are different from those recommended by WHO. Introduction of MDT has resulted in a rapid reduction of prevalence, but not in the detection rate, which has remained more stable. Rapp. trimest. statist. sanit. mond., 44 (19911 Zambia 7 469 cases Prevalence rate: 8.8 per 10 OOO Detection rate: 0.7 per 10 OOO MDT coverage: 81.6% The country is divided into 9 provinces and the leprosy control programme is combined with the tuberculosis programme at national level, but is fully integrated into the general health services and the PHC system. MDT was introduced in the country in 1983 and total coverage is planned for 1991. Level 118 Level IIB includes countries where leprosy en- demicity is medium and leprosy control provides MDT to <75% of known patients. In these countries, the goal is to reduce within 5 years the endemicity level of the disease. The main objectives are: to extend the existing MDT coverage to at least 75% of known cases; to improve early case finding; and to prepare integration of leprosy control where leprosy control is specialized. Ethiopia 31 753 cases Prevalence rate: 6.8 per 10 OOO Detection rate: 1.1 per 10 OOO MDT coverage: 54% Leprosy is considered to be one of the major public health problems in Ethiopia. The programme is partly integrated, and there are plans to improve detection activities and to implement progressive decentralization. MDT was introduced in 1983 and after 5 years, prevalence has been reduced to 75%. Ghana 7 773 cases Prevalence rate: 5.2 per 10 OOO Detection rate: 1.03 per 10 OOO MDT coverage: 61.2% The country is divided into 10 administrative regions and 110 districts. The leprosy control programme is vertical, based on leprosy workers at the district level. MDT started in 1984, and with the constant reduction in prevalence, it is planned to review the present control strategy with a view to integrating it into the PHC system. Kenya Lesotho Mauritania Niger 3 198 cases Prevalence rate: 1.3 per 10 OOO Detection rate: 0.3 per 10 OOO MDT coverage: 73% 188 cases Prevalence rate: 1.1 per 10 OOO Detection rate: 0.14 per 10 OOO MDT coverage: 58.5% 1 343 cases Prevalence rate: 6.6 per 10 OOO Detection rate: 0.4 per 10 OOO MDT coverage: no information 6 277 cases Prevalence rate: 8.8 per 10 OOO Detection rate: 0.9 per 10 OOO MDT coverage: 6.6% The country is divided into 7 departments and lep- rosy control activities are vertically organized and based, in each department, on one mobile team responsible for the control of endemic diseases and immunization. MDT was introduced in 1983 and Wld hlth statist. quart., 44 (19911 19 - progress in coverage is very slow, owing to the immensity of the country and the dispersed popula- tion. Reunion Rwanda 155 cases Prevalence rate: 2.6 per 10 OOO Detection rate: 0.04 per 10 OOO MDT coverage: 18% 1 065 cases - 56 PB; 1 009 MB Prevalence rate: 1.5 per 10 OOO Detection rate: 0.2 per 10 OOO MDT coverage: 17.2% Leprosy control activities are partly integrated into the general health services, under the supervision of mobile specialized teams. MDT was introduced in 1981 and at this time, the regimens adopted were different from those recommended by WHO. Since 1988, the programme provides the WHO MDT regi- mens and it is planned to develop a combined leprosy-tuberculosis programme. Seychelles 41 cases Prevalence rate: 5.9 per 10 OOO Detection rate: 0.5 per 10 OOO MDT coverage: 46.3% Sierra Leone 1 680 cases Prevalence rate: 4 per 10 OOO Detection rate: 2.5 per 10 OOO MDT coverage: 65.7% The country is divided into 4 regions, and the lep- rosy control programme is vertically organized. With the introduction of MDT and the shorter duration of treatment, prevalence has fallen rapidly, and compli- ance and follow-up of patients have improved, but the workload of health personnel has remained the same or even increased. Swaziland Uganda 338 cases Prevalence rate: 4.3 per 10 OOO Detection rate: 0.2 per 10 OOO MDT coverage: 12.4% 15 OOO cases (estimation) Prevalence rate: 8.1 per 10 OOO Detection rate: 0.6 per 10 OOO MDT coverage: 17.3% The country is divided into 10 regions and 33 dis- tricts. Leprosy control activities are partly integrated into the general health structure. MDT was intro- duced in 1983, and in some areas the programme has been interrupted because of social instability. From 1988, plans were initiated to develop a combined leprosy-tuberculosis programme. Zaire 13 242 cases - 1 O 066 PB; 3 176 MB Prevalence rate: 3.7 per 10 OOO Detection rate: 0.9 per 10 OOO MDT coverage: 66.4% The country is divided into 9 provinces, the leprosy control programme is combined with the tuberculo- sis programme at national level, but is fully inte- grated into the general health services and the PHC system. MDT was introduced in 1983, using different regimens to those recommended by WHO. Since 1988, the programme delivers WHO regimens and is being progressively started in the districts. Total coverage is planned for 1991. - 20 - Level II/A Level IIIA includes countries where leprosy endem- icity is high and leprosy control provides MDT to at least 33% of known patients. In these countries, the goal is to reduce within 5 years the current prevalence to Level II by treating all known cases with MDT. The main objectives are: to extend the existing MDT coverage; to improve early case finding; and to prepare the integration of leprosy control after the workload has been reduced. Cameroon 12 302 cases - 9 085 PB; 3 217 MB Prevalence rate: 10.9 per 10 OOO Detection rate: 0.96 per 10 OOO MDT coverage: 35.3% The country is divided into 10 provinces and leprosy control activities are completely integrated into the general health services. At the central and provincial levels, there is a combined programme for leprosy and tuberculosis. Gabon Guinea Bissau 2 491 cases Prevalence rate: 21.3 per 10 OOO Detection rate: 1.3 per 10 OOO MDT coverage: 52% 1179 cases - 618 PB; 418 MB; 143 NK Prevalence rate: 11.9 per 10 OOO Detection rate: 2.13 per 10 OOO MDT coverage: 100% The country is divided into 3 provinces, 8 regions and 37 districts. Since 1980, leprosy control is com- bined with tuberculosis and is being progressively integrated into the PHC system. MDT was introduced in 1986, with an intensive starting phase of daily rifampicin treatment for MB patients. Madagascar 19 210 cases Prevalence rate: 16 per 10 OOO Detection rate: 1.6 per 10 OOO MDT coverage: 12% The country is divided into 6 provinces and about 200 medical districts. The leprosy control pro- gramme is integrated into the general health ser- vices. MDT was introduced in 1985 but is still limited to the pilot areas and private centres. A national plan of action has been designed, with implementation intended to start in 1990, aiming at the generaliza- tion of MDT over a period of 5 years. Level 11/8 Level 1118 includes countries where leprosy endem- icity is high and leprosy control provides MDT to less than 33% of known patients. In these countries, the goal is to reduce within 5 years the endemicity level of the disease to Level II by treating at least 75% of all known cases with MDT. The main objectives are: to extend the existing MDT coverage to at least 75% of known cases; to improve early case finding; and to prepare the integration of leprosy control after the workload has been reduced. Benin 5 655 cases - 1 825 MB; 2 221 PB Prevalence rate: 11.9 per 10 OOO Detection rate: 1.5 per 10 OOO MDT coverage: 30.4% Leprosy is considered to be the fifth most important health problem in the country. While there is a plan to progressively integrate leprosy control activities into PHC, at present the programme is still vertical. MDT was introduced in 1987 and covers 5 of the 6 provinces. The regularity of treatment is 87-90% for patients treated with MDT. It has been observed that the introduction of MDT is followed by a rapid drop in prevalence and an increase in the case- detection rate. Burkina Faso 13 312 cases - 2 302 MB; 11 010 PB Prevalence rate: 14.8 per 10 OOO Detection rate: 1.65 per 10 OOO MDT coverage: 8% The country is divided into 30 provinces and 300 districts. Leprosy control is partly integrated, with specialized personnel at the intermediate level to organize and supervise activities. MDT has been introduced in 15 provinces in 1990 and should be generalized throughout the whole country within 3 years. Cape Verde Central African Republic 491 cases Prevalence rate: 12.9 per 10 OOO Detection rate: 1 per 10 OOO MDT coverage: 13% 7 096 cases - 5 707 PB; 1 389 MB Prevalence rate: 24.4 per 10 OOO Detection rate: 1.5 per 10 OOO MDT coverage: 29.4% The country is divided into 5 regions and the leprosy control programme is combined with the tuberculo- sis and trypanosomiasis programmes at national level. MDT was adopted as the basis of the national leprosy control programme in 1986. Chad 10 651 cases - 8 926 PB; 1 725 MB Prevalence rate: 18.8 per 10 OOO Detection rate: 0.9 per 10 OOO. MDT coverage: 6.3% The country is divided into 14 prefectures and 6 health sectors. Leprosy control is partly integrated, but specialized mobile teams are responsible for detection activities. Complete integration into the general health structure is planned for 1990. MDT was introduced in 1984. Congo 6 416 cases Prevalence rate: 32.2 per 10 OOO Detection rate: 1 per 10 OOO MDT coverage: 3.8% The country is divided into 10 health areas. The national leprosy control programme is partly inte- grated or still vertical and combined with other programmes (tuberculosis, trypanosomiasis, schisto- somiasis, immunization). MDT was · introduced in 1985. Cote d'Ivoire 24 291 cases - 20 669 PB; 3 622 MB Prevalence rate: 19.3 per 10 OOO Detection rate: 1.8 per 10 OOO MDT coverage: 9.5% Rapp. trimest. statist. sanit. mond., 44 (1991) -21- The country is divided into 26 rural health sectors and leprosy control is being integrated into the general health structure, particularly in the areas where MDT is used. MDT was introduced in 1983. Guinea 15 818 cases - 1 871 PB; 376 MB; 13 571 NK Prevalence rate: 23 per 10 OOO Detection rate: 1.3 per 10 OOO MDT coverage: 14% The country is divided into 4 regions. The leprosy control programme is based on the PHC approach. MDT was introduced in 1986 and a national plan of action aiming at the coverage of the whole country within 5 years started in 1989. Mali 22 121 cases - 17 874 PB; 4 247 MB Prevalence rate: 23.6 per 10 OOO Detection rate: 1.7 per 10 OOO MDT coverage: 3.3% Since 1985 leprosy control (considered as a priority by the government) has been integrated into PHC structures. In 1981 MDT was started in a specialized centre, and in 1987 became the basis of the country's leprosy-control programme. Mozambique 24 338 cases - 830 PB; 731 MB; 22 777 NK Prevalence rate: 15.5 per 10 OOO Detection rate: 0.9 per 10 OOO MDT coverage: 6.4% Leprosy control activities are combined with the tuberculosis programme and are partially integrated into the general health structure. MDT was intro- duced in 1984 but could only be implemented in the capital city of each province and in 9 districts, because of the political situation. Nigeria 193 715 cases - 44 609 PB; 12 078 MB; 137 028 NK Prevalence rate: 17.1 per 10 OOO Detection rate: 0.5 per 10 OOO MDT coverage: 4.3% More than 40% of registered cases in the WHO African Region are in Nigeria. The country is divided into 22 states. Leprosy and tuberculosis control are considered as priority programmes by the federal government. The leprosy-control programme is based on treatment with MDT through the PHC approach. MDT was introduced in 1985, but is lim- ited to 11 states. Senegal 11 554 cases - 7 580 PB; 3 974 MB Prevalence rate: 15.7 per 10 OOO Detection rate: 0.7 per 10 OOO MDT coverage: 12.6% The country is divided into 10 administrative regions and 30 departments, and leprosy control is mainly vertical. MDT was introduced in 1982 in a pilot area, then expanded to 2 departments per year since 1986. Togo 3 987 cases - 2 504 PB; 1 483 MB Prevalence rate: 11.5 per 10 OOO Detection rate: 1.3 per 10 OOO MDT coverage: 4.7% Leprosy control activities are essentially vertical. MDT was introduced in a pilot area in 1986. A Wld hlth statist. quart., 44 (19911 national programme plans to expand MDT through- out the whole territory by 1995, and to integrate activities into the general health structure. Future prospects Leprosy remains an important public health problem in Africa, and the countries of the western and central part of the continent notify very high preva- lence and detection rates. A majority of countries in the region have imple- mented the WHO-recommended MDT regimens as a basis for their leprosy control. However, MDT cover- age is low and is increasing slowly as compared with other WHO regions. The reasons for such slow progress are numerous, and mainly related to the operational aspects of leprosy control in a difficult socioeconomic context. However, with the increasing political commitment in many countries to control leprosy through MDT, and with the constant decline of leprosy prevalence (mainly due to the update of data during MDT implementation), a new interest has been shown for leprosy control in Africa. Consequently, high priority is now given to treat all registered cases with MDT, especially in level II and Ill countries. During this stage, efforts should be made to improve case detec- tion by the PHC approach and community involve- ment. The most important technical and operational con- straints in leprosy control have been identified and discussed during the interregional conference on leprosy control in Africa, held in November 1989. The major recommendations of this conference were as follows: • The great opportunity for bringing about major reductions in the prevalence of leprosy in the African countries as a result of the availability of effective MDT technology, as recommended by WHO, and the considerable resources available through national and international nongovernmental organizations (NGOs) and other agencies, should be fully utilized. • The primary responsibility for control of leprosy should remain with the ministries of health, which should work in close collaboration with all parties participating in the programme. This coordination could best be achieved through the development of national coordinating committees under the leader- ship of the ministries of health, and tripartite agree- ments between governments, WHO, and supporting national and international NGOs and other agencies. • Political commitment to leprosy control is ex- tremely important for successful control of the dis- ease, and this commitment should be translated into the development of national plans of action with clear targets for the implementation of MDT. • Experience with MDT so far has demonstrated it to be effective, safe and practicable in a variety of situations. The operational problems of implement- ing MDT can be resolved in a cost-effective manner. Health systems research should be encouraged, with a view to solving several of the operational prob- lems. • Leprosy control through MDT should be carried out within integrated services. Integration means that leprosy control activities should be part of de- - 22 - centralized, comprehensive and permanent health services which are as close to the community as possible. Such integration is best achieved at the district level, based on the PHC approach, and should be carefully planned. Specialized technical (supervisory) support for leprosy control activities must remain available within the integrated pro- grammes. • Building national capabilities for leprosy control with particular emphasis on management is crucial for proper implementation of leprosy control through MDT. While external personnel are of value on a short-term basis, the long-term future of lep- rosy control depends entirely on the building of national capabilities. The appointment of a national leader is vital to the success of the programme. • In integrated programmes, it is even more important that not only the general health services personnel and current leprosy workers are trained and retrained, but in addition, that leprosy control as a subject (including practical training) should be an integral part of the curricula for undergraduate medical training as well as for the training of para- medical personnel. • Appropriate health and public education of patients, health workers and the community within the framework of general health promotion is impor- tant to gain the support of all concerned for leprosy control. Such support would help in removing the existing stigma and would aid case-finding and treatment compliance. SUMMARY The African Region has the second largest preva- lence of leprosy among the WHO regions with about 1 per 1 OOO population affected. With a very uneven distribution among countries, the region currently has a total of about 480 OOO registered cases. The number of new cases detected per year is reported to be about 37 000. A high proportion (25-40%) of the registered cases are estimated to have significant physical disabilities. In spite of the introduction of multidrug therapy (MDT) in the early 1980s, currently only about 20% of the patients are benefiting from this improved treatment. The major problem in the low MDT coverage appears to be operational, against the background of a difficult socioeconomic situation. However, there have been favourable trends towards increased political commitment in several countries in recent years. The operational and technical constraints were discussed at an inter- regional conference in Brazzaville in 1989 which emphasized the need to make use of the op- portunities to reduce disease prevalence through MDT; to coordinate various internal and external resources available for leprosy control; to increase political commitment and develop plans of action to build national capabilities for leprosy control; to integrate leprosy control within general health ser- vices; and to promote health education. RESUME La lepre dans la Region OMS de I' Afrique La Region africaine, avec un taux d'environ 1 pour 1 OOO, se situe au deuxieme rang des regions de l'OMS pour la prevalence de la lepre. Le nombre total des cas enregistres, tres inegalement repartis entre les pays, est actuellement de l'ordre de 480 000. Environ 37 OOO cas nouveaux seraient depis- tes chaque annee. On estime qu'une forte proportion (25-40%) des cas enregistres est atteinte d'invalidites physiques importantes. Malgre !'introduction de la polychimiotherapie (PCT) au debut des annees 80, quelque 20% seulement des malades beneficient actuellement de ce traitement ameliore. La faiblesse de la couverture par la PCT semble etre due surtout a des problemes operationnels, lies a une situation socio-economique difficile. Depuis quelques annees, cependant, une evolution se dessine dans plusieurs pays en faveur d'un engagement politique accru. Les obstacles operationnels et techniques ont ete exami- nes lors d'une conference interregionale qui a eu lieu en 1989 a Brazzaville, OU a ete soulignee la necessite de saisir les occasions offertes par la PCT de reduire la prevalence de la maladie, de coordon- ner les diverses ressources interieures et exterieures disponibles pour la lutte antilepreuse; de renforcer !'engagement politique et d'elaborer des plans d'ac- tion en vue de doter les pays d'un potentiel pour la lutte antilepreuse; d'integrer la lutte antilepreuse dans les services de sante generaux; et, enfin, de promouvoir !'education sanitaire. Rapp. trimest. statist. sanit. mond., 44 (19911 - 23 - THE NATIONAL LEPROSY ERADICATION PROGRAMME IN INDIA B. N. Mittal• The disease leprosy has been in existence in the Indian subcontinent for several centuries. Informa- tion regarding its extent and distribution was how- ever very meagre until recently. The 1931 census gave the number of leprosy cases as 150 OOO. Since then anti-leprosy work has been intensified, especi- ally in the post-independence years after 1948, and more particularly after the National Leprosy Control Programme was launched by the Government of India in 1955. The estimated number of cases has subsequently been rising in successive decades, the estimates for 1941, 1951, 1961, 1971, 1981 and 1991 being 1.5, 2.0, 2.5, 3.2, 4.0 and 5.0 million re- spectively. The main factors responsible for this progressive increase were: • rapid increase in the population; • increased case-finding activities; and • increased voluntary reporting due to community awareness. Magnitude of the problem The estimated number of leprosy patients in the country is 4 million, based on the 1981 census population of 684 million. This accounts for one- third of the global leprosy load. About 15% of these patients are children. The lepromatous proportion ranges from 10-25% in different areas, and the de- formity rate is approximately 20%. The disease en- demicity varies widely in the country. The pre- valence rates exceed 5 per 1 OOO in 196 out of 445 districts in the country. Nearly 435 million people live in these 196 districts. At the end of June 1990, there were 2.4 million registered patients in the country. 0.47 million new cases were detected during the year 1989-1990, and about 0.67 million patients were discharged. The • Leprosy Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Nirman Bhawan, New Delhi, India. magnitude of the problem is therefore vast, and the consequent need to achieve control gains greater urgency in the context of attaining our social objec- tive of health for all by the year 2000. Distribution of leprosy cases Although the disease is found throughout the country, it is not equally distributed in this subconti- nent. There is a wide variation in prevalence, even in low-endemicity areas with pockets of high endem- icity. However, a definite pattern can be established demarcating high-, moderate- and low-endemicity areas. Variation in the prevalence of the disease and its geographical distribution can be seen in Map 1. The areas of high prevalence are found mainly in the south-eastern and central parts of the country. The areas of high prevalence include the states of Tamil Nadu, Andhra Pradesh, Orissa, Bihar, Madhya Pradesh, Uttar Pradesh, Maharashtra and West Bengal (Table 1). These 8 states account for ap- proximately 90% of the total registered case load in the country. The prevalence rates mentioned above are average figures for the entire state. The geographical dis- tribution of leprosy differs considerably, not only from state to state but also at district and village levels. Table 2 provides complete information on all the states. Strategies The leprosy control programme has been in oper- ation since 1955, but only since 1980 has it received high priority. It was redesignated as National Lep- rosy Eradication Programme (NLEP) in 1983, with the goal of arresting the disease in all known leprosy patients by the turn of century. The programme has been included in the country's high-priority 20-point programme since 1980. The strategies formulated for achieving the above objectives are: TABLE 1. AREAS OF HIGH PREVALENCE TABLEAU 1. ZONES DE FORTE PR~VALENCE Andhra Pradesh .. Bihar ....... . Madhya Pradesh . . Maharashtra . . . . Orissa ....... . State/Union territory Etat/territoire de !'Union Tamil Nadu ............ . UttarPrad~h ............ . West Bengal - Bengale occidental ............... . Wld hlth statist. quart., 44 (19911 Population, 1990 Cases on record, June 1990 Prevalence rate per 1 OOO (estimate - estimation) Cas enregistres, juin 1990 Taux de prevalence pour 1 OOO (OOO) 64 311 83 946 65 096 78 773 31 669 58138 138 410 65 548 283 866 465 553 203 250 181 459 182 487 378 444 367 234 287 296 4.41 5.55 3.12 2.30 5.76 6.51 2.65 4.39 - 24 - MAP 1. PREVALENCE OF REGISTERED LEPROSY CASES IN INDIA, JUNE 1990 CARTE 1. PREVALENCE DES CAS DE LEPRE ENREGISTRES EN INDE, JUIN 1990 G)(,/(xl '" . ' /, •. •. 'JAMMU & /, ;rii ..... ~ 1 • .l-• KASHMIR X ... ' . • • JC )( )t • It )( • , ...... ,,., ........... KARNATAKA Prevalence rate per 1 OOO Tau• de prevalence pour 1 OOO D<0.9 GIT] ITIIIIl] 1 -1.9 2-4.9 ~5 MEGHALAYA W. BENGAL iif! PONDICHERRY LAKSHADWEEP ANDAMAN & NICOBAR ISLANDS Note: The designations employed and the presentation of material on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries - Les designations utilisees sur cette carte et la presentation des donnees qui y figurent n'impliquent, de la part de !'Organisation mondiale de la Sante, aucune prise de position quant au statut juridique de tel ou tel pays, territoire, ville ou zone, ou de ses autorites, ni quant au trace de ses frontieres. • early detection and regular treatment of patients; • provision of multidrug therapy (MDT) to all patients; • education of patients, their families and com- munities about the disease and its curability; and • rehabilitation of patients with a view to making them economically self-reliant and socially ac- ceptable. Infrastructure The magnitude of the case load and the high en- demicity in the country dictated deployment of specially-trained vertical staff for rendering leprosy services. In the low-endemicity districts, the primary health care staff provide these services. As the case load decreases, the vertical staff will be gradually withdrawn, ultimately integrating leprosy services into the primary health care system. An extensive infrastructure has come into being over the years (Box 1). In the rural areas, leprosy services are carried out by the leprosy control unit, while its counterpart in the urban areas is the urban leprosy centre. In the low-endemicity districts, survey, edu- cation and treatment centres are attached to a primary health care centre in the area. Each leprosy Box 1. National Leprosy Eradication Programme, India-infrastructure as of June 1990 Type of facility Survey, education and treatment centres Urban leprosy centres Leprosy control units/modified leprosy control units Temporary hospitalization units Voluntary organization projects District leprosy units Reconstructive surgery units Leprosy training centres Sample survey/assessment units Number 6 097 894 719 291 287 244 75 49 39 Rapp. trimest. statist. sanit. mond., 44 (1991) - 25 - control unit caters to 0.4-0.5 million people and is manned by four nonmedical supervisors, and 20 paramedical workers. Each urban leprosy centre covers a population of 30 000-50 OOO, and its techni- cal staff comprises a paramedical worker/nonmedical supervisor responsible to the medical officer of a dispensary or a hospital. Each survey, education and treatment centre serves about 25 OOO people, with the assistance of a paramedical worker under the guidance of a medical officer. Temporary hospitalization wards have been es- tablished to provide specialized care to those who need it. A limited number of reconstructive surgery units provide surgical services to needy patients. To augment the availability of trained manpower, specialized leprosy training centres have been de- veloped to organize courses for the training of para- medical workers, nonmedical supervisors, laboratory technicians and physiotechnicians. In addition, task- oriented courses of short duration are conducted to impart specialized training in multidrug therapy (MDT). The National Leprosy Eradication Commission over- sees the programme under the chairmanship of the Union Health Minister. This commission is assisted by the National Leprosy Eradication Board which has the Union Health Secretary as its chairman and an officer of the rank of deputy director-general as its secretary. The National Leprosy Eradication Commis- sion is responsible for policy formulation while the National Leprosy Eradication Board looks after its planning and implementation. Components of the National Leprosy Eradication Programme (NLEP) A brief outline of the important components under the NLEP is presented below. Case detection, which is crucial to the NLEP, par- ticularly for the prevention of deformities, consists of both passive and active case detection, and includes mass surveys, school surveys and contact surveys. Laboratory services include skin-smear examination, a prerequisite for disease classification before start- ing treatment. Treatment delivery is essentially the distribution of drugs by a team including a medical officer at predetermined points. The drug regimen for pauci- bacillary (PB) leprosy patients is the same as that recommended by WHO. However, in case of multi- bacillary (MB) leprosy, an intensive therapy phase is added, which consists of daily supervised adminis- tration of rifampicin 600 mg, clofazimine 100 mg and dapsone 100 mg for 14 days. This is followed by the regimen recommended by WHO for MB leprosy patients. Procedures for classification of disease, treatment schedules, disease activity, recognition of adverse drug reaction, monitoring of drug compli- ance and surveillance procedures have been laid out in a manual. A system of information and monitoring has been evolved to ensure smooth and coordinated progress of planned activities. A case card is prepared for each new patient at the time of registration. The data TABLE 2. PREVALENCE OF REGISTERED LEPROSY CASES BY STATE, INDIA, JUNE 1990 TABLEAU 2. PREVALENCE DES CAS DE LEPRE ENREGISTRES PAR ETAT, INDE, JUIN 1990 State/Union territory Population 1981 Population, 1990 Cases on record,June 1990 Prevalence rate per 1 OOO Etat/territoire de l'Union (estimate - estimation) Cas enregistres, juin 1990 Tauxde prevalence pour 1 OOO (000) (000) 1. Andhra Pradesh ...... 53 550 66876 241 223 3.61 2. Arunachal Pradesh ..... 632 789 1 249 1.58 3. Assam ...... 19 911 24866 18 731 0.75 4. Bihar ............ 69 523 86825 463 072 5.33 5. Delhi ............ . . . . . . . 6 220 7 768 3 985 0.51 6. Goa ........ 1 008 1 259 1 545 1.23 7. Gujarat ....... 34086 42 567 25083 0.59 8. Haryana ....... 12 923 14 652 872 0.06 9. Himachal Pradesh 4 281 5 346 4383 0.82 10. Jammu & Kashmir . 2 719 3395 3 704 1.09 11. Karnataka ....... 37136 46 377 87 934 1.90 12. Kerala ......... 25454 31 788 57146 1.80 13. Madhya Pradesh ..... 52 124 65096 203 250 3.12 14. Maharashtra ............. 62 784 78 773 181 459 2.30 15. Manipur .... ............. 1 421 1 775 1 409 0.79 16. Meghalaya .. 1 338 1 671 1 552 0.93 17. Mizoram ... . ........ 494 617 410 0.66 18. Nagaland ... .......... 775 968 1 832 1.89 19. Orissa ..... ............. 26370 32 933 133 419 4.05 20. Punjab - Pendjab . ............ 1 679 20 968 3 526 0.17 21. Rajasthan ..... 32 262 40 291 14 613 0.36 22. Sikkim ........ 316 394 307 0.78 23. Tamil Nadu ..... 48408 60 455 255 717 4.23 24. Tripura ....... 2 053 2 564 2 500 0.98 25. Uttar Pradesh ... 11 086 138410 367 234 2.65 26. West Bengal - Bengale occidental 54 581 68164 287 079 4.21 27. Andaman & Nicobar .......... 189 236 1 284 5.45 28. Chandigarh . . . . . . . . . . . . . . . . 452 564 1 875 3.32 29. Daman & Diu ........... 79 99 254 2.58 30. Dadra & Nagar Haveli . . . . . 104 129 540 4.17 31. Lakshadweep . . . . . . . . . . 40 50 208 4.14 32. Pondicherry - Pondichery .. 604 755 3 292 4.36 Total ............... 685 185 • 847 421 a 2 370 687 2.80 a Figures have been rounded - Chiffres arrondis. Wld hlth statist. quart., 44 (1991) - 26 - generated in the field are reported through suc- cessive echelons of districts and state to the Central Directorate. In addition, the programme was sub- jected to an in-depth independent evaluation in 1986, 1987 and 1989 by the Government of India and WHO. Health education, and community participation, are important components of the NLEP. The prime ob- jectives of health education are to increase aware- ness about leprosy, encourage self-reporting and treatment compliance, and also to dispel stigma against leprosy. Progress with leprosy control Case detection, treatment and discharge Annual performance is assessed on the achievement of targets allotted for new case detection, treatment and discharge by each state. On average 0.4-0.5 million new cases are being detected annually. The number of cases discharged as cured is pro- gressively increasing every year (Fig. 1). In general, targets are met and often exceeded. over 1.57 million patients had completed MDT by March 1990. Moreover, 33 low-endemicity districts are being brought under MDT with the help of the existing primary health care system. In districts yet to be brought under MDT, leprosy patients who have not responded to dapsone mono- therapy for two years or more are being identified and put on MDT. Impact of MDT MDT is very well accepted by patients, the tolerance is good and side-effects are minimal. Drug compli- ance is excellent as shown by high attendance rates and regularity of drug intake, assessed by tablet/ capsule counts. There is a marked reduction in reactive episodes. MDT has improved motivation among patients, staff and community. More patients are being discharged as cured after successful com- pletion of therapy, and there is increased awareness and knowledge about leprosy in the community. This is reflected in increased voluntary reporting of FIG.1 ANNUAL NEW LEPROSY CASE DETECTION AND CASE DISCHARGE PERFORMANCE, INDIA, 1980-1990 EVOLUTION DU NOMBRE DE CAS NOUVEAUX DE LEPRE DEPISTES ET DES CAS CLASSES, PAR AN, INDE, 1980-1990 600~ i I I 5001 ·- I E i ~ 400--j c: ., "' :, 0 2 300 c: 0 ·; ,; 1200 100 Case detection Cas depistes Case discharge Cas classes 0-+-~~~~~~~~~-,-~~~~~~--,-~~~~~~~~~--r~~---; 80-81 81-82 82-83 83-84 84-85 85-86 86-87 87-88 88-89 89-90 Years -Annees During the year 1987 the annual case discharge was 10% higher than the annual new case detection; this increased to 25% in 1988 and 38% during 1989. At the end of June 1990, 2.4 million leprosy patients were on record, of which a high proportion were under regular treatment. Over 4.5 million patients have been discharged as disease cured/migrated/ dead, since the inception of the programme. MDT coverage At present 130 endemic districts with a population coverage of 283 million and 2.15 million leprosy patients, are in districts covered by MDT. In addition, new patients. The relapse rate is very low (< 1%), indicating that MDT is effective. There has been a significant improvement in the information system, as more reliable data are now available on the magnitude of the leprosy problem in the country. The epidemiological impact assessed in 12 districts where the MDT programme has been in progress for five or more years shows that there is a marked reduction in the prevalence rate, annual new case-detection rate, MB ratio, child rate and deformity rate (Table 3). However, the reduction in deformity rate may be attributed to the discharge of a large number of previously-treated patients from the active register. The number of "leprosy free" villages is also increasing. Rapp. trimest. statist. sanit. mond., 44 (1991) - 27 - TABLE 3. EPIDEMIOLOGICAL IMPACT OF MULTIDRUG THERAPY (MOTi, 12 DISTRICTS IN INDIA TABLEAU 3. IMPACT EPIDEMIOLOGIQUE DE LA POLVCHIMIOTHERAPIE (PCTI, 12 DISTRICTS DE L'INDE Indicator lndicateur At commencement of MDT Au depart delaPCT March1989 Reduction Mars 1989 Reduction (%) Prevalence rate per 1000 - Taux de prevalence par 1000 .............. . 9.8 3.4 65.3 New case-detection rate per 1000 - Taux de depistage de cas nouveaux par 1000 3.1 1.8 42.0 Multibacillary ratio(%) - Taux de cas multibacillaires (%) ............. . 24.7 21.3 13.8 Child rate(%) - Taux de cas infantiles (%) ...................... . 18.8 16.3 13.3 Deformity rate(%) - Taux de deformations(%) ................... . 7.6 2.7 64.5 Number of villages with leprosy patients - Nombre de villages comptant des lepreux. 15 487 11 251 27.4 At present MDT coverage is extended to more than 65% of patients in the country. It is proposed that MDT be extended to all 196 endemic districts by the year 1992. This will cover about 90% of patients in the country. Rehabilitation 75 reconstructive surgery units and 13 leprosy re- habilitation promotion units are functioning under the programme to cater to the physical and vo- cational rehabilitation needs of patients. The Min- istry of Welfare has developed a scheme for provid- ing grant-in-aid to voluntary organizations involved in vocational rehabilitation services. A scheme for employment/self employment of lep- rosy affected/cured persons is being formulated as well as a scheme for setting up regional shoe units. Voluntary organizations In India, voluntary organizations have played a pioneering role all through the history of leprosy control in the country. Voluntary services for leprosy patients all over the country have been extensively expanded since 1951. Currently, about 287 voluntary organizations are actively engaged in leprosy relief services in India. Budget 139 million rupees were spent during 1985-1986 on programme activities. This increased to 152.8 million rupees (US$ 8.5 mil- lion) in 1986-1987, 176.2 million (US$ 9.8 million) in 1987-1988, 190 million (US$ 10.6 million) in 1988-1989 and 200 million (US$ 11.1 million) during 1989-1990. Besides this the state/Union territories have spent twice this amount, towards the cost of maintaining the existing infrastructure. International support The Swedish International Development Agency (SIDA) has been supporting the MDT programme in India since 1978, under a trilateral agreement with the Government of India and WHO. UNICEF and the Leprosy Mission are supporting the MDT pro- gramme in several districts. Besides these, other major organizations supporting the programme are: DANIDA, American Leprosy Missions, LEPRA, Amici Wld hlth statist. quart., 44 ( 1991) di Raoul Follereau (Italy), Damien Foundation, Sasakawa Memorial Health Foundation and the German Leprosy Relief Association. Support from WHO The World Health Organization is supporting the programme in several ways: - technical support through NLEP consultants and consultant leprologists; - regional review meetings; - annual meeting of state leprosy officers and vol- untary organizations; - independent evaluation of the programme; - fellowships for research and educational ac- tivities; - material and equipment; - monitoring various projects. Future plans and strategies Extension of MDT MDT coverage will be extended to all the endemic districts in the country by 1992, which will put nearly 90% of leprosy patients in the country on MDT. MDT coverage for low-endemicity districts will be provid- ed through the primary health care infrastructure. In addition, once the intensive operations in the first 5-7 years are completed in the MDT districts, the primary health care staff will take over the respon- sibilities of the programme in a phased manner. The district leprosy supervisory staff will continue to provide technical guidance for the programme. Training activities will be intensified, to provide short-duration task-oriented courses. Monitoring and evaluation The monitoring and evaluation act1v1t1es will con- tinue at all levels, and will include a nationwide rapid sample survey, to revalidate data on the mag- nitude of the problem of leprosy in the country. It is also proposed to make an in-depth epidemiological assessment of districts which have completed five years of MDT in order to assess its impact. Rehabilitation The proposed schemes for rehabilitation of leprosy affected/cured persons, and the establishment of district rehabilitation centres, will be initiated in coordination with other ministries and nongovern- mental organizations. - 28 - Constraints Classification. There is general concern that some MB patients may be wrongly classified as PB, and consequently receive insufficient treatment, leading to the risk of rifampicin-resistant strains of M. leprae emerging. On the other hand in some areas (state and institutions) there is a tendency to classify multi- lesional PB cases as MB, leading to an increase in the proportion of MB cases. There is a need to prepare guidelines for use under field conditions. Persistence of lesions. Some PB leprosy patients are reluctant to discontinue treatment even after adequate chemotherapy due to persistence of lesions. There is also reluctance among doctors to discontinue treatment in such cases. This leads to an unnecessary increase in the duration of treatment for PB leprosy patients. Complications. There is a need to provide adequate facilities to manage complications (e.g. reactive epi- sodes and plantar ulcers). The existing referral fa- cilities need to be fully utilized for this purpose. Disability prevention. This area is grossly neglected. There is a need to train patients, their families and health staff in methods of prevention of new dis- abilities, and to provide adequate facilities and sup- port for correction of existing disabilities. Reversal reaction and relapse. It is difficult to distin- guish between reversal reaction and relapse (especi- ally among PB patients under surveillance). Ap- propriate guidelines are necessary to distinguish these two phenomena, and for their management under field conditions. Magnitude of the problem. A major constraint in assessing progress of the programme has been the inadequacy of information about the true magnitude of the problem. The estimates derived from sample surveys done years ago are unrealistic. There is an urgent need to reassess the problem by undertaking a nationwide sample survey. Surveillance of patients after completing treatment. Due to the risk of relapse and late reversal reactions, patients should be periodically examined both clini- cally and bacteriologically. This activity needs to be properly planned, and adequate resources must be provided for this important activity. Operational constraints Plan of action. There is a need to formulate an action plan for extending MDT to all districts, especially the low-endemicity districts. There is also a need to prepare action plans to integrate the programme into the primary health care system, especially in districts where the programme has been in oper- ation for five years or more. Drug compliance. It is important that drug compli- ance be ensured by regular supervisory visits for tablet/capsule counts and proper health education. This should include an appropriate defaulter- retrieval mechanism. Introduction of "blister pack" formulation may be useful in monitoring this ac- tivity. Manpower. Shortage of adequately trained doctors, laboratory technicians, physiotherapy technicians and health educators has been an important con- straint in MDT implementation. In some instances trained staff have been transferred and replaced by untrained staff. Availability of drugs. The logistics of drug supply from the central to the peripheral level often involve considerable delay. This sometimes results in short- age of drugs or receipt of drugs close to the date of expiry. Transport. There are some difficulties in maintaining MDT vehicles due to administative bottlenecks at state/district level. Laboratory services. There is a need to improve training of manpower, provision of proper equip- ment, and introduction of quality checks for this important activity. Managerial aspects. Supervisory activities in the field need strengthening at all levels. This is prob- ably the most important area of operational con- straint. Urban leprosy control. With regard to MDT im- plementation in urban areas, there is a need to utilize existing urban health services through ap- propriate training of all personnel, including private medical practitioners. Administrative and financial constraints Community participation. Health education activities should be expanded, in order to enhance community awareness and participation in the programme. Financial resources. A major constraint is the lack of adequate financial resources and budgetary pro- visions, especially in the area of health education, rehabilitation and operational research. lntersectoral coordination. Although attempts are being made to involve other related sectors in the programme, the progress seems to be rather slow. SUMMARY India has the largest leprosy problem in the world, with an estimated 4 million patients. The number of registered cases in the country was 2.4 million by June 1990, and the number of new cases detected during 1989-1990, 0.47 million. The disease preva- lence varies widely from state to state and even among districts within states - 8 of the 26 states contribute to 90% of all the registered cases. The country has a high priority for leprosy and the National Leprosy Eradication Programme (NLEP) aims to arrest the disease among all known cases in the country by the turn of the century through a Rapp. trimest. statist. sanit. mond., 44 (1991) - 29 - strategy which includes multidrug therapy (MDT), early case detection, health education and rehabilita- tion. The specialized leprosy infrastructure in the country has a total of about 8 500 establishments including 719 leprosy control units, 244 district lep- rosy units and 49 training centres. By June 1990, 130 districts with 2.15 million patients had come under MDT. It is planned to cover 196 districts by 1992, ensuring coverage for 90% of the patients in the country. The country spends approximately 600 mil- lion rupees (US$ 33.3 million) per year on NLEP. In addition, a number of bilateral and international agencies including nongovernmental organizations participate in the programme. WHO supports the NLEP through technical inputs, monitoring and evaluation, and training. Plans to integrate leprosy control within primary health care, particularly after completion of the intensive phase of MDT, are being developed. Operational and technical constraints are constantly reviewed in order to find optimal solutions. RESUME Le programme national d'eradication de la lepre en lnde L'lnde est le pays ou le probleme de la lepre revet la plus grande ampleur, avec, selon les estimations, 4 millions de patients. Le nombre de cas enregistres dans le pays s'elevait a 2.4 millions en juin 1990 et le nombre de cas nouveaux deceles en 1989-1990 a 470 OOO. La prevalence de la maladie varie con- siderablement d'un Etat a l'autre, et meme entre districts a l'interieur des Etats - 8 des 26 Etats enregistrent 90% du total des cas. Le pays accorde une priorite elevee a la lepre et le programme national d'eradication de la lepre (National Leprosy Eradication Programme - NLEP) vise a stopper la maladie parmi les cas connus dans le pays d'ici la fin du siecle, au moyen d'une strategie reposant sur la polychimiotherapie (PCT), le depistage precoce des cas, !'education pour la sante et la readaptation. L'infrastructure specialisee du pays comprend au total pres de 8 500 etablissements, dont 719 unites de lutte antilepreuse, 244 unites de districts et 49 Wld hlth statist. quart., 44 (19911 centres de formation. En juin 1990, 130 districts, representant 2 150 OOO patients, etaient couverts par la PCT. En 1992, 196 districts devraient etre couverts, ce qui equivaudrait a une couverture de 90% des patients. L'lnde depense environ 600 millions de roupies (US$ 33,3 millions) par an pour son pro- gramme national d'eradication de la lepre. En outre, plusieurs organismes bilateraux et internationaux, y compris des organisations non gouvernementales, participent a ce programme. L'OMS y contribue sous forme d'apports techniques et d'activites de sur- veillance et d'evaluation et de formation. Des plans visant a integrer la lutte antilepreuse dans les soins de sante primaires, notamment a la fin de la phase intensive de PCT, sont actuellement mis au point. Les obstacles techniques et operationnels sont cons- tamment passes en revue pour trouver des solutions optimales. - 30 - LEPROSY CONTROL IN ZAMBIA G. J. Steenbergen• Leprosy is an endemic disease in Zambia that repre- sented a serious public health problem in the past in terms of prevalence and incidence. The disease is spread evenly around the country. Initially treatment was confined to intramural care in 19 leprosaria, but this strategy was abandoned in favour of outpatient- based treatment. Progressively the old leprosaria were closed or converted to cater for short- and medium-term leprosy and rehabilitation care only. Meanwhile a few severely disabled dependent patients remain in some mission-operated centres for social reasons only. Initially, treatment for leprosy was confined to dapsone monotherapy. In 1983, following the recom- mendations of the WHO study group on chemo- therapy of leprosy for control programmes (1982), all new cases, relapses and cases suspected of dapsone resistance were put on multidrug therapy (MDT). Since 1985, with the support of the Sasakawa Mem- orial Health Foundation of Japan, the remaining case load is reviewed and converted to MDT or treatment is stopped. A country profile is given in Box 1. Box 1. Country profile, Zambia, 1990 Demographic Total population: 8 068 846 Crude birth rate: 49.8 per 1 OOO population Crude death rate: 13.1 per 1 OOO population Natural growth rate-1985-1990: 3.72% per year · 1990-1995: 3.83% per year Infant mortality rate: 89.6 per 1 OOO live births Life expectancy: 54 years Health services Hospitals-Government Mission Industrial Total Health centres Urban Rural Total Number 43 29 10 82 185 642 827 Top 5 causes of mortality and morbidity (expressed as a function of severity and frequency) 1. Malaria 2. Respiratory infections 3. Diarrhoea 4. Malnutrition 5. Tuberculosis and AIDS • National Leprosy-Tuberculosis Specialist. Beds 8339 3965 1 602 13 906 Organization Leprosy control is combined with tuberculosis con- trol and fully integrated into the general health services, as a programme thrust of primary health care. The leprosy-tuberculosis control unit of the Ministry of Health has three full-time workers. The unit is headed by the national leprosy-tuberculosis special- ist. The field units responsible for leprosy control are the provincial and district health management teams. They carry operational responsibility for the implementation of the control programme, as part of their primary health care effort. These teams prepare annual action plans, in which leprosy-control ac- tivities are represented. In each province (9) and in each district (56), leprosy- tuberculosis control officers provide the respective provincial and district teams with technical advice and support. They are also responsible for the tech- nical monitoring and implementation of the pro- gramme. Technical supervision and teaching of health staff are the most important activities of this cadre of staff. All provinces and districts are visited at least once a year by the leprosy-tuberculosis control unit. Implementation of multidrug therapy (MDT) The treatment of leprosy, using MDT (the regimen recommended by WHO in 1982) as the routine mode, was introduced in 1983. The proportion of cases on MDT as of December 1989 is shown in Map 1. The decision to convert a patient to MDT or stop treatment is made by the district leprosy- tuberculosis control officer. The health centre staff are responsible for the follow-up and clinical moni- toring. The trend in registered and new cases (1981- 1989) is shown in Fig. 1 & Map 2. As of July 1990, MDT had been introduced in 52 districts (93%). as described above. The actual conversion of the case load to MDT has however been much slower than anticipated. Fig. 2 shows the provincial coverage of MDT on the active case load as of 31 December 1989; Fig. 3 & Map 3 show new case notification. One of the main reasons for the delay is the limited possibility of the supervisory district staff to go out on a regular basis. This reflects the adverse economic conditions of the country and the limited access to transport and operational funds at district level. Leprosy, being an integrated component of primary health care, has to compete for its share with other health priority programmes. Training While the programme utilizes general health workers for the implementation of MDT, it still requires the Rapp. trimest. statist. sanit. mand., 44 (1991) - 31 - FIG. 1 REGISTERED AND NEW LEPROSY CASE LOAD, ZAMBIA, 1981-1989 • CAS ENREGISTRES ET CAS NOUVEAUX DE LEPRE, ZAMBIE, 1981-1989 • -;;; -0- c <I> ~-~ =>= o·- -5 .s -;;;"' "'"' <I> u "'"' u "O - "' 0 ~ ~ .c "' E .c O ~z z 20 18 16 14 12 10 8 6 4 2 0 1111 Registered Enreg istres New Nouvea ux 1981 1982 1983 1984 1985 1986 1987 1988 1989 Yea rs - Annees a Registered: on active treatment reg ister at 3 1 December; new: notified as new cases during the year - Enregistres: sur le registre du traitement actif au 3 1 decembre; nouveaux: notifi es comme cas nouveaux pendant l'annee. MAP 1. PROPORTION OF LEPROSY CASES ON MULTIDRUG THERAPY (MDT) , ZAMBIA, DECEMBER 1989 CARTE 1. PROPORTION DES CAS DE LEPRE SOUS POL YCHIMIOTHERAPIE (PCT), ZAMBIE, DECEMBRE 1989 1. Central 2. Copperbelt 3. Easte rn 4. Luapula 5. Northern 6. North-Western 7. Southern 8. Western 9. Lusaka skills and specialized knowledge of key programme officers. Their function is to serve as resource per- sons to the provincial and district health manage- ment teams, and to act as a catalyst to focus leprosy control in their area. Technical supervision and teaching of general staff are part of their duties. Nurses have traditionally been somewhat neglected in staff development, yet they represent a cadre that enjoys the best contacts with patients. The plan for staff development now includes nurses as valuable resource persons for the further expansion of the programme and improved patient relations. Laboratory services Skin-smear services are the backbone of leprosy classification. This service has been routinely im- Wld hlth statist. quart. , 44 (1991 ) Percentage on MDT Pourcentage sous PCT D 40-50 ~ 50-75 ~ 75 - 100 plemented in all districts. District laboratories carry out the procedure as part of their general duties. A total of 92 laboratories are thus able to do skin- smear examinations. Most skin smears are either taken by the touring district leprosy-tuberculosis control officer or the labo~atory technician. Quality control is effective through periodic reviews of stained smears by the national reference labora- tory (chest diseases laboratory). The staff of the laboratory also make on-site v isits to review the procedures. Skin smears are taken upon diagnosis of all new cases, and when fin ishing the course of treatment of multibacillary cases. Skin smears are also taken in the case of a suspected relapse or treatment failure. - 32 - FIG. 2 PERCENTAGE OF REGISTERED LEPROSY CASES ON MULTIDRUG THERAPY (MDT), BY PROVINCE, ZAMBIA, DECEMBER 1989 POURCENTAGE DE CAS DE LEPRE ENREGISTRES TRAITES PAR POLYCHIMIOTHERAPIE (PCT), PAR PROVINCE, ZAMBIE, DECEMBRE 1989 100 80 Q) "' "' 'i: Q) 60 ~ :, 0 0.. I Q) "' 40 "' 'i: ~ 1l :;; ;2 0.. 20 0) 0 i 0 ai "' ~ .0 "S "' :;; c. "' "' .3 c. :, c. ...J 0 u Province MAP 2. REGISTERED LEPROSY CASE LOAD, ZAMBIA, 31 DECEMBER 1989 CARTE 2. TOTAL DES CAS DE LEPRE ENREGISTRES, ZAMBIE, 31 DECEMBRE 1989 1. Central 2. Copperbel t 3. Eastern 4. Luapula 5. Northern 6. North -Weste rn 7. Southern 8. Western 9. Lusaka Rehabilitation Multidrug therapy does not address the problems of leprosy-related disabilities. Clinical evaluation of the disease (during and after treatment) , and its develop- ment of nerve lesions in particular, are part of the routine follow-up procedures. However, in a few districts a reliable clinical review takes place. In order to involve the patient and the community in a more meaningful way in the prevention of dis- abilit ies, a special programme for disability preven- tion in leprosy was formulated. The programme aims at a reduction of disability development through the act ive participation of the patients and the community. It uses the concept of community- based rehabilitation, in the framework of primary Number of cases Nombre de cas D 128-152 ~ 152 - 273 ~ 273 - 335 ~ 335 -504 ~ 504- 925 health care. Its significance lies in the more broad- based approach to leprosy disability. Initially the programme will focus on foot care, while expanding later to other disabilities. With the support of the Leprosy Mission Inter- national (UK), this programme started in 1990 with the intake of 9 pilot districts. The impact of MDT The impact of MDT on the leprosy situation in Zambia has been quite dramatic (Box 2). The intro- duction of strict discharge criteria and reduced treat- ment durations have dropped the registered case Rapp. trimest. statist. sanit. mond., 44 (199 1) - 33 - Box 2. Leprosy profile, Zambia, 1989 Paucibacillary Multibacillary Total Number of active cases, 31 December 1989 1 720 1 943 3 663 Number of new cases in 1989 322 255 577 Annual case-detection rate, 1989 (per 100 OOO population) 4.14 3.28 7.42 Number of cases cured in 1989 896 1 019 1 915 Number of cases defaulted in 1989 (3 months or more) 461 412 873 Annual default rate, 1989 22 .6% 18.7% 20.6% Number of cases on MDT, 31 December 1989 1 150 1 398 2 548 Coverage of MDT(%), 31 December 1989 66.8% 71.9% 69.5% Leprosy trend (1981-1989) Year 1982 1983 1984 1985 1986 1987 1988 1989 Register 37/ 12 16 642 New cases (annual) 1 010 15 183 13 738 12 155 10 492 10 139 6 095 3 663 1 440 1 138 1 033 960 565 481 577 FIG. 3 NEW LEPROSY NOTIFICATIONS, BY PROVINCE AND TYPE, ZAMBIA, 1989 NOTIFICATIONS DE CAS NOUVEAUX DE LEPRE, PAR PROVINCE ET PAR TYPE, ZAMBIE, 1989 150-.---~~~~~~~~~~~~~~~~~~~~~------, 120 90 "' rn <.) Q) -0 Q) .0 60 E 0 z 30 0 oi .c lo c. c. 0 u rn :, c. rn :, ...J load to much lower levels. This is partly a direct reflection of MDT (shorter treatment periods and less resistance development), but the improved con- trol procedures with a more focused approach stim- ulated a more aggressive discharge policy in many districts. Presumably cured patients were kept for an unnecessarily long time on the registers in the past. With the (MDT induced) "clean-up" operation of the registers, a more accurate picture of the real active case load was created. Epidemiology A marked reduction in prevalence of active leprosy has been a steady trend since 1985. Yet the level of Wfd hfth statist. quart., 44 (1991 ) Province • Multibacillary - Multibacillaire • Paucibacilla ry - Paucibacillaire c: ~ Q) 3: .c t:: 0 z ~ rn "' :, ...J new case detection in absolute numbers has not demonstrated a similar trend. Crude case-detection rates dropped over the years, but th is is mainly due to population increase. Although lower case-detection rates are a promising feature of reduced rates of infection, age-adjusted rates need to be calculated in order to come to more valid conclusions. On the basis of current statistics, it is not possible to determine the attributable effect of MDT on the reduction of case-detection rates in real terms. In addition the incubation period of leprosy is too long to expect such an effect in the relatively short time since the introduction of MDT. - 34 - MAP 3. ANNUAL LEPROSY CASE-DETECTION RATE, ZAMBIA, 1989 CARTE 3. TAUX ANNUEL OE DEPISTAGE DES CAS DE LEPRE, ZAMBIE, 1989 1. Central 2. Copperbelt 3. Eastern 4. Luapula 5. Northern 6. North-Western 7. Southern 8. Western 9. Lusaka Operational review The National Leprosy Tuberculosis Control Pro- gramme, which uses MDT implementation as the main thrust fo r the leprosy control effort, has intro- duced a few operational monitoring adjustments. A new simplified reporting system has been success- fully introduced in recent years. In this system a single form is filled by the districts on a quarterly basis. This quarterly report represents the consolidated returns of the district. Health cen- tres also provide information to the districts on a monthly basis on a simplified single form. The monthly report form is combined with tuberculosis. A crucial component of the new reporting system is the regular feedback from the central unit to all reporting centres. This feedback is simply presented in a national overview illustrated with simple graphics, where each centre can compare its per- formance with centres in other areas. This has en- hanced feelings of participation among field staff, and has improved compliance with the national policy. Acceptance by patients and the community MDT has given leprosy a new face. The old stigmatic beliefs of incurability of leprosy are disappearing. The good cure rates, combined with the relatively short treatment durations, have improved compli- ance tremendously. Default rates are markedly the highest in provinces where the implementation of MDT is lagging behind . Logistical support The supply of MDT drugs and other implements is organized by the central unit. It distributes the sup- Case detection rate per 100 OOO population Taux de detection pour 100 OOO habitants D 3-4 ~ 4-4 ~ 4-7 ~ 7 - 13 PD 13 -20 pl ies to the provincial centres on a 6-monthly basis, while provincial buffer stocks are also available. The drugs are a free donation from the Sasakawa Memorial Health Foundation of Japan. This vital support has ensured that the programme has an uninterrupted supply of MDT drugs. Conclusions The National Leprosy Control Programme enjoys a good reputation among the primary health care pro- grammes of the Ministry of Health. It is credited with a marked reduction in leprosy prevalence since the introduction of MDT, thus considerably reducing the leprosy burden of the health services. Due to operational simplicity, standardization and predictability, the programme has gained significant momentum, while enjoying a much broader oper- ational base. While these developments are encouraging, it is too soon to expect a complete eradication of leprosy in the near future, given the continued low level of observed new case detection. The implementation of MDT, while progressively improving its coverage, still lags behind the project- ed targets. Thus the observed beneficial effect of MDT, in terms of reduction of leprosy prevalence, represents only part of its potential. Not ignoring the needs of disabled leprosy patients, who are bacteriologically cured or on effective chemotherapy, a programme of disability prevention in leprosy has been formulated and was due for implementation in 1990. Rapp. trimest. statist. sanit. mond., 44 11991) - 35 - SUMMARY Leprosy was a serious public health problem in Zambia until recently, with over 16 OOO cases in 1982. Since then leprosy patients in the country have been put under multidrug therapy (MDT), as recom- mended by WHO, with support from the Sasakawa Memorial Health Foundation. Leprosy control in Zambia is combined with tuberculosis control and integrated within general health services. By 1990 52 districts (93%) had MDT, with an overall coverage of about 70% of all patients. As a result the number of registered cases has come down steadily from 16 642 in 1982 to 3 663 in 1989. Similarly, the number of new cases detected has been reduced from 1 010 cases in 1982 to 577 in 1989. On the whole the programme has gained significant mo- mentum, although it is too early to expect a com- plete eradication of the disease in the near future, given the continued low level of observed new cases. Further, the implementation of MDT still lags behind the projected targets so that the potential of MDT is not being fully utilized. In addition, the problem of rehabilitation of disabled patients needs special attention. A subprogramme aimed at reduc- ing disability through community participation is being developed within the framework of primary health care. RESUME Lutte antilepreuse en Zambie La lepre posait recemment encore un serieux pro- bleme de sante publique en Zambie ou on comptait, en 1982, plus de 16 OOO cas. Depuis lors, selon une recommandation de l'OMS et avec l'appui de la Fondation Sasakawa pour la Sante, les malades sont traites par la polychimiotherapie (PCT). La lutte contre la lepre est, en Zambie, associee a la lutte antituberculeuse et integree dans les services de sante generaux. En 1990, la PCT etait appliquee dans 52 districts (93%) et couvrait 70% des malades, et le nombre des cas enregistres a constamment decline, passant de 16 642 en 1982 a 3 663 en 1989. De meme, le nombre des cas nouveaux depistes est passe de 1 010 en 1982 a 577 en 1989. Dans Wld hlth statist. quart., 44 (19911 !'ensemble, l'action antilepreuse a pris un essor considerable, mais ii est trap tot pour escompter une eradication complete de la maladie dans un avenir proche car, si les cas nouveaux sont peu nombreux, on continue neanmoins a en observer. En outre, !'application de la PCT est en retard par rapport aux objectifs fixes, et son potentiel n'est pas complete- ment utilise. Entin, le probleme de la readaptation des malades incapacites merite une attention speciale, et un sous-programme a participation com- munautaire visant a reduire l'incapacite est en cours d'elaboration dans le cadre des soins de sante primaires. - 36 - LEPROSY CONTROL ACTIVITIES OF THE INTERNATIONAL FEDERATION OF ANTI-LEPROSY ASSOCIATIONS Dominique Martineau-Needham• & Sarah Laceyb The International Federation of Anti-leprosy Associa- tions (ILEP) is a working community of 22 non- governmental organizations raising funds from the general public in the North for the support of anti- leprosy work in the South (1). Relationships between Members are governed by one basic principle: each Member association is an autonomous organization in its own right, making its own decisions according to its own priorities. ILEP was founded in 1966, first as a federation of 11 European associations known as ELEP (the European Federation of Anti-leprosy Associations). In 1975, with the admission of Members from North America and the Pacific region, ELEP became ILEP. Scope of ILEP activities As stated in its constitution, "The objectives of ILEP are to support medical, scientific, social and human- itarian activities throughout the world for the relief and rehabilitation of persons suffering from leprosy, and for the prevention and eventual eradication of that disease". In 1988, ILEP Members supported 814 field projects in some 92 countries, in addition to 136 specific projects (research and other activities) with a total annual expenditure of approximately US$ 60 million (2). The diversity in Members' priorities and interests is reflected by the wide variety of projects they support: from the small leprosy clinic in the bush to the nationwide leprosy control programme; from experimental scientific research to rehabilitation of ex-leprosy patients. Most ILEP Members have de- veloped or are currently developing their own strategy for the 1990s focusing on the control and eventual eradication of leprosy. In 1988, the larger part of Members' support was concentrated on leprosy control activities, account- ing for 72% of total Federation resources; field staff training accounted for some 12% of resources, re- search for 10%, with diverse socioeconomic ac- tivities totalling 6% (2). ILEP - a coordinating body ILEP Members work together through a coordination system established to improve efficiency, to focus resources where they are most needed, to set common standards and, in general, to make the most economical use of financial and human re- sources. This coordinating system, the cornerstone of the Federation, revolves around the following main components: • Assistant General Secretary, ILEP, London, United Kingdom. • Scientific Officer, ILEP, London, United Kingdom. c All statistics on ILEP patients are taken from the ILEP Directory 1988 (2, 3). • Working sessions. Members meet together in June and December each year to plan the alloca- tion of resources to projects. Working groups on specific topics, such as training, evaluation tools and collaboration with Third World leprosy as- sociations, also convene during these meetings. • Coordinators. One Member is appointed to coor- dinate grants and activities in a given geographi- cal area. • Medical Commission. An international body of medical experts provides the Federation with advice on the various aspects of leprosy. • A project management information system. The body of tools and procedures, both manual and computerized, which allows for the coordination of grant-giving by Members. Data collection and production of statistical reports Standardized procedures for the collection of data on leprosy and for their use in the production of statistical reports have been devised for the use of Members and cooperators in the field. Data from all projects supported by Members are collected by means of standardized reporting forms and a centralized computerized data base on all leprosy activities is maintained, allowing for easy access to and retrieval of data. Financial and statisti- cal reports on Federation activities facilitate the coor- dination of grant-giving by Members and permit the identification of gaps in Members' support. They may also highlight general trends in leprosy work and generate appropriate action (3). Great care is taken by Members and their field representatives to collect accurate data, but approximately 30% of the projects supported by Members are not in a position to supply data on their activities. Patients registered in ILEP-supported field projectsc Classification of patients Patients registered in ILEP-supported projects are classified into three categories: (i) chemotherapy-patients who are receiving anti- bacterial chemotherapy; (ii) surveillance-patients who have completed the required course of chemotherapy but are still kept under surveillance because of the danger of relapse; (iii) care-patients who are bacteriologically cured but who are still suffering from sequelae of the disease and are still in need of non-specific treatment, such as treatment of plantar ulcers, physiotherapy and/or surgery for paralysis, health education, etc. Rapp. trimest. statist. sanit. mond., 4411991) - 37 - Distribution of patients according to the three categories New and discharged patients in ILEP-supported projects, 1985-1988 Fig. 1 shows the distribution of patients according to the above categories. The number of patients under treatment has decreased whilst the number of patients under surveillance and care has shown an opposite trend. This change in pattern is largely attributed to the successful completion of multidrug therapy (MDT), allowing a large number of patients to be released from control. Fig. 2 illustrates the trends in new and discharged patients. New patients are those patients who have never previously received anti-bacterial treatment. Discharged patients are those released from control (i.e. removed from the treatment register after suc- cessful completion of chemotherapy). The introduc- tion of MDT had resulted in an increasing number of patients being released from control up until 1987. In -;;; -~ E "' "O c: ::l :, 0 :s "' E Q) -~ a.. FIG. 1 DISTRIBUTION OF PATIENTS ACCORDING TO THREE CATEGORIES (CHEMOTHERAPY, SURVEILLANCE AND CARE), 1985-1988 REPARTITION DES PATIENTS EN FONCTION DE TROIS CATEGORIES (CHIMIOTHERAPIE, SURVEILLANCE ET SOINS), 1985-1988 1 400~~~~~~~~~~~~~~~~ 1200 "'- 1000 "O "' c: - ct:l .~ ~:: o E ,:;- -'=-"' "'E C.~ Q)~ ·~ ~ c. Q) _.,, O Q) di .0 .o E E o :,z z 1986 1987 1988 Years - Annees FIG. 2 --8--- Total pat ients Chemotherapy Chimiothera pie - - Surveillance Surveillance Care Soins NEW AND DISCHARGED PATIENTS IN ILEP-SUPPORTED PROJECTS, 1985-1988 PATIENTS NOUVEAUX ET PARTIS DANS LES PROJETS DE L'ILEP, 1985-1988 180 160 140 120 100 80 60 40 20 0 1985 1986 198 7 Years - Annees - New patients Nouveaux patients 1988 - Discharged Partis Wld hlth statist. quart., 44 (1991) - 38 - 1988, however, this pattern was not sustained. This would suggest that in previous years some of the discharged patients were in fact old cases who had already completed treatment but had remained on the treatment register. They were discharged when MDT commenced and the registers were revised. During the same period the number of new patients showed a similar pattern with an increase until 1987 and a decrease in 1988. Table 1 contains data which show that the propor- tion of children (<15) among all new cases recorded annually in ILEP-sponsored projects has been in- creasing over the period 1985-1988. The proportion of disabled patients among all new cases has de- creased. This could indicate an improvement in lep- rosy services which are now able to detect cases at an earlier stage. Table 2 is a list of all the new cases detected in ILEP-supported projects in 1988, by country. It should be noted that the figures given refer to the actual coverage by ILEP-supported projects. This might differ from figures from national health ser- vices when nationwide coverage is achieved. ILEP involvement in national leprosy aontrol programmes In 1988, 55% of resources distributed by Members for activities in the field were allocated to national/ regional programmes, compared with 45% for local/ private programmes. 90% of the patients supported by ILEP Members in Africa were registered in national leprosy control programmes. This trend towards greater cooperation with government pro- grammes seems likely to continue. ILEP Members are increasingly signing agreements with govern- ments for the implementation or the development of national leprosy control programmes. Recently there have been initiatives in Nigeria and Mexico as well as in India. In a number of countries tripartite collaboration between the government, WHO and an ILEP Member has been established, resulting in improved planning and monitoring of leprosy activities and more efficient allocation of resources. In 1988, Members supported the activities of national leprosy programmes in 75 countries, mainly through leprosy control activities, but also in the form of expertise, training and the supply of anti- leprosy drugs. Use of multidrug therapy (MDT) in ILEP- supported projects Background In 1981, the WHO recommendations on MDT were endorsed by the ILEP Medical Commission and the WHO MDT drug regimens recommended to ILEP Members. In 1982, a resolution to make provisions to implement the new MDT regimens, notably in the framework of national programmes, was approved by the 14th ILEP General Assembly. Subsequently, in 1983, a booklet was published by ILEP for its Mem- bers, entitled The introduction of multidrug therapy for leprosy (4). From this time the number of pro- jects employing MDT for patient treatment has steadily grown. Use of MDT, 1984-1988 Whilst the vast majority of ILEP-sponsored field pro- jects utilize the WHO standard drug regimens, there are some projects where other MDT regimens are employed. No distinction is made here be- tween such regimens. In 1988, over one-third of the patients undertaking a course of chemotherapy in ILEP-supported projects were receiving MDT. Since 1984, the first year for which computerized data on MDT were maintained, there has been a marked increase from 8% to 35.3% of patients on chemo- therapy. This trend is illustrated in Fig. 3. Table 3 gives details of the proportion of all patients on chemotherapy receiving MDT in 1988. Nearly 42% of patients on chemotherapy in Asia were receiving MDT, compared with 32% in the Americas and 27% in Africa. Constraints/limitations of implementing MDT The latest global figures on MDT published in the Leprosy epidemiological bulletin (5) show that at the end of 1988, 39.55% of the 4.2 million patients regis- tered for chemotherapy worldwide were receiving MDT. This proportion is similar to the 35.26% of the 768 761 patients registered for chemotherapy in ILEP-sponsored projects who were receiving MDT at the end of 1988. The actual number of leprosy cases worldwide in need of treatment is unknown but has been estimated at around 10 million. Within the Federation there is a growing awareness that the pace of MDT implementation should be speeded up in order to bring MDT to as many leprosy patients as possible within the shortest possible time span. Many countries with good health infrastructures have already introduced MDT. In others, the original stringent prerequisites for starting MDT may be act- ing as a block to its introduction or to the extension of coverage. The recently published ILEP medical bulletin (6) contains recommendations aimed at overcoming some of the potential constraints in order to initiate action in areas where MDT coverage is low. Wider application of MDT could be achieved by using a fixed duration of treatment, such as 24 months for multibacillary (MB) patients, by using TABLE 1. NEW PATIENTS REGISTERED FOR TREATMENT IN ILEP-SUPPORTED PROJECTS, 1985-1988 TABLEAU 1. NOUVEAUX PATIENTS ENREGISTRES EN VUE D'UN TRAITEMENT DANS LES PROJETS DE L'ILEP, 1985-1988 Categories-Categories All new patients - Total nouveaux patients New children - Nouveaux enfants .... . New disabled - Nouveaux handicapes .. . New children(%) - Nouveaux enfants (%). New disabled(%) - Nouveaux handicapes (%) 1985 86 920 16 676 43 810 19.18 50.40 1986 92 524 18 377 11 379 19.86 12.29 Cumulative total 1987 1988 Total cumule 108140 101 492 389 076 22 418 22 200 79 671 12 181 8988 76 358 20.73 21.87 20.47 11.26 8.86 19.62 Rapp. trimest. statist. sanit. mond., 44 ( 19911 TABLE 2. DETAILS OF NEW PATIENTS REGISTERED FOR CHEMOTHERAPY IN ILEP-SUPPORTED PROJECTS IN 1988 • TABLEAU 2. DETAIL DES NOUVEAUX PATIENTS ENREGISTRES EN VUE D'UNE CHIMIOTHERAPIE DANS LES PROJETS DE L'ILEP EN 1988 • Countries/areas Children Adults Total new cases Disabled Pays/zones Enfants Adultes Total nouveaux Handicapes cas MB PB MB PB Angola .......................... 2 3 20 35 60 16 Benin - Benin ...................... 3 44 125 510 682 0 Central African Republic - Republique centrafricaine. 3 45 37 462 547 438 Cameroon - Cameroun ......... 9 84 145 752 990 53 Comoros - Comores ........... 6 17 20 47 90 7 Equatorial Guinea - Guinee equatoriale 0 1 8 20 29 4 Ethiopia - Ethiopie 191 326 1 542 1 854 3 913 391 Gabon ....... 0 4 23 150 177 0 Gambia - Gambie 4 21 35 140 200 26 Ghana ...... 10 139 237 883 1 269 53 Kenya ....... 4 22 39 164 229 15 Liberia - Liberia 17 65 171 229 482 18 Malawi ...... 7 132 228 760 1 127 206 Niger ...... 0 15 40 72 127 46 Nigeria - Nigeria 62 282 589 1197 2 130 98 Rwanda ...... 2 4 10 15 31 7 Senegal - Senegal 9 58 171 388 626 56 Sierra Leone . . . . 1 209 119 691 1 020 69 Somalia - Somalie 5 38 109 106 258 28 South Africa - Afrique du Sud 4 4 25 45 78 37 Sudan - Soudan 0 29 60 163 252 42 Swaziland .... 0 2 3 10 15 6 Togo ....... 5 45 71 287 408 66 Tunisia - Tunisie 0 0 20 10 30 12 Uganda - Ouganda. 18 246 166 998 1 428 120 United Republic of Tanzania - Republique-Unie de Tanzanie ..... 12 157 190 697 1 056 206 Zaire - Zai"re ... 2 14 15 182 213 84 Zambia - Zambie . 26 33 81 105 245 5 Zimbabwe .... 0 0 0 0 0 38 Africa - Afrique . 402 2 039 4 299 10 972 17 712 2147 Argentina - Argentine 3 3 140 102 248 17 Bolivia - Bolivie 1 10 20 26 57 5 Brasil - Brasil 221 596 1 833 2 183 4833 697 Colombia - Colombie 37 41 498 287 863 224 Dominican Republic - Republique dominicaine 14 47 71 117 249 20 Ecuador - Equateur 6 9 65 59 139 12 Guyana ........ 2 10 10 32 54 5 Haiti - Hai"ti ..... 5 43 77 151 276 42 Jamaica - Jamai"que 0 3 7 5 15 3 Paraguay ... 16 9 282 123 430 47 Peru - Perou 0 0 0 2 2 0 Suriname. 2 10 7 22 41 0 Uruguay ... 0 0 15 6 21 1 Americas - Ameriques . 307 781 3 025 3115 7 228 1 073 Afghanistan ....... 2 2 21 23 48 12 Bangladesh ....... 71 235 944 1 213 2 463 500 Bhutan - Bhoutan ... 0 2 26 29 57 13 Cambodia - Cambodge 28 21 398 98 545 0 China b - Chine b ... 1 8 105. 51 165 40 India - lnde ...... 1 454 15 568 12 586 33 848 63456 3809 Indonesia - lndonesie 210 474 1 406 1 218 3 308 292 Myanmar .... 17 15 39 107 178 47 Nepal - Nepal ..... 13 28 814 525 1 380 364 Pakistan ........ 123 42 1 053 205 1 423 332 Philippines ....... 9 15 85 94 203 27 Republic of Korea - Republique de Coree 2 1 30 29 62 12 Sri Lanka ........ 8 161 154 800 1 123 39 Thailand - Tha"ilande . 60 96 1 248 692 2 096 269 Asia - Asie ... 1 998 16 668 18 871 38 932 76 507 5 756 Turkey - Turquie 17 5 24 11 Europe ...... 17 5 24 11 Papua New Guinea - Papouasie-Nouvelle-Guinee 2 0 0 3 0 Oceania - Oceanie 2 0 0 3 0 Total lLEP . .... 2 710 19 490 26250 53024 101 474 8 981 a Cumulation by country - Totaux cumules par pays. ' The statistics from China do not include the following data from Taiwan Province: 18 new cases in adults (12 MB and 6 PB; - disabled) - Les statistiques de la Chine ne comprennent pas les donnees suivantes concernant la Province de Taiwan: 18 cas nouveaux chez les adultes (12 MB et 6 PB; 1 handicap€!). - 40 - FIG.3 USE OF MULTIDRUG THERAPY (MDT) IN ILEP-SUPPORTED PROJECTS, 1984-1988 UTILISATION DE LA POLYCHIMIOTHERAPIE (PCT) DANS LES PROJETS DE L'ILEP, 1984-1988 1400 1200 1000 '§ ."! E 800 ~ "Cl c "' ~ 600 ~ 0 ? ~ c Q) 400 -~ 0.. 200 0 1984 TABLE 3. TABLEAU 3. 1985 - MDT PCT 1986 1987 Years - Annees DETAILS OF PATIENTS RECEIVING MULTIDRUG THERAPY (MDT) IN PROJECTS SUPPORTED BY ILEP MEMBERS, 1988 • 19 88 DETAIL DES PATIENTS TRAITES PAR POLYCHIMIOTHERAPIE (PCT) DANS LES PROJETS SOUTENUS PAR LES MEMBRES DE L'ILEP, 1988 • All patients on chemotherapy Patients receiving MDT %MDT Countries/areas end December 1988 end December 1988 on all patients Pays/zones Total patients sous chimioth6rapie Patients traites par PCT % PCT fin decembre 1988 fin decembre 1988 par rapport total patients MB PB Total MB PB Total MB PB Total Angola . . ... 136 62 198 136 62 198 100.00 100.00 100.00 Benin - Benin . 1 693 4 614 6 307 717 534 1 251 42.35 11.57 19.84 Burkina Faso . . 1 808 11 504 13 312 0 0 0 0.00 0.00 0.00 Burundi ... .. 53 77 130 53 77 130 100.00 100.00 100.00 Central African Republic Republique centrafricaine 1 300 5 772 7 072 181 262 443 13.92 4.54 6.26 Cameroon - Cameroun 3 217 9 085 12 302 1 562 2 776 4338 48.55 30 .56 35.26 Chad - Tchad .. . . 1 725 8 836 10 561 122 553 675 7.07 6.26 6.39 Comoros - Comores 58 25 83 58 25 83 100.00 100.00 100.00 Congo . .. ... . 2 893 5 786 8 679 54 114 168 1.87 1.97 1.94 Cote d'Ivoire . .. . 11 181 22 362 33 543 978 2 393 3 371 8.75 10.70 10.05 Egypt - Egypte .. 3 637 4 791 8 428 3 637 4 791 8 428 100.00 100.00 100.00 Equatorial Guinea Guinee equatoriale .. . . 13 34 47 11 32 43 84.62 94.12 91.49 Ethiopia - Ethiopie 14 753 12 194 26 947 13162 3 890 17 052 89.22 31 .90 63.28 Gabon ....... 661 2 096 2 757 350 492 842 52.95 23.47 30.54 Gambia - Gambie 323 117 440 323 117 440 100.00 100.00 100.00 Ghana . . . . . . 3 078 7 003 10 081 1 365 657 2 022 44.35 9.38 20.06 Guinea - Guinee 766 4 973 5 739 73 257 330 9.53 5.17 5.75 Kenya . ...... 1 782 3 369 5 151 712 555 1 267 39.96 16.47 24.60 Liberia - Liberia 1 663 2 926 4 589 731 1 042 1 773 43.96 35.61 38.64 Madagascar . .. 2 057 2 929 4 986 214 483 697 10.40 16.49 13.98 Malawi . . .... 1 369 655 2 024 1 369 655 2 024 100.00 100.00 100.00 Mali .. ..... . 4247 17 874 22 121 380 317 697 8.95 1.77 3.15 Morocco - Maroc . 2 681 682 3 363 0 0 0 0.00 0.00 0.00 Niger .... . . .. 2 736 3 958 6 694 451 568 1 019 16.48 14.35 15.22 Nigeria - Nigeria . 16 516 16 040 32 556 3 767 3 052 6 819 22.81 19.03 20.95 Rwanda ....... 1 009 56 1 065 153 30 183 15.16 53.57 17.18 Senegal - Senegal 3 660 5436 9 096 532 216 748 14.54 3.97 8.22 Sierra Leone ... . 1 186 1 309 2 495 1 002 539 1 541 84.49 41.18 61.76 Somalia - Somalie 413 199 612 413 199 612 100.00 100.00 100.00 South Africa - Afrique du Sud . 174 58 232 174 58 232 100.00 100.00 100.00 Sudan - Soudan 340 1 314 1 654 204 575 779 60.00 43.76 47.10 Swaziland .. .. . . 19 23 42 19 23 42 100.00 100.00 100.00 Togo . .. . . . . .. 1 483 2 504 3 987 6 0 6 0.40 0.00 0.15 Tunisia - Tunisie .. 53 92 145 53 92 145 100.00 100.00 100.00 Uganda - Ouganda . 2 116 5 850 7 966 838 1 082 1 920 39.60 18.50 24.10 Rapp. trimest. statist. sanit. mond., 44 I 1991) - 41 - TABLE 3 (continued) TABLEAU 3 (suite) All patients on chemotherapy Patients receiving MDT %MDT Countries/areas end December 1988 end December 1988 on all patients Pays/zones Total patients sous chimioth0rapie Patients traites parPCT %PCT fin decembre 1988 fin decembre 1988 parrapporttotal patients MB PB Total MB PB Total MB PB Total United Republic of Tanzania - Republique-Unie de Tanzanie 3 523 3 782 7 305 2 800 2 808 5 608 79.48 74.25 76.77 Zaire - Za'ire ... 4085 10 103 14188 1 966 5493 7 459 48.13 54.37 52.57 Zambia - Zambie . 358 257 615 210 265 475 58.66 100.00 77.24 Zimbabwe .... 280 77 357 280 77 357 100.00 100.00 100.00 Africa - Afrique . 99 045 178 824 277 869 39 056 35 161 74 217 39.43 19.66 26.71 Argentina - Argentine 2 725 2 564 5289 2 504 2 544 5 048 91.89 99.22 95.44 Bolivia - Bolivie ... 502 384 886 473 307 780 94.22 79.95 88.04 Brazil - Bresil ..... 29402 22 994 52 396 4379 1 685 6064 14.89 7.33 11.57 Colombia - Colombie 12 885 6 535 19 420 7 034 4053 11 087 54.59 62.02 57.09 Dominican Republic Repu- blique dominicaine 1 935 1 037 2 972 990 442 1 432 51.16 42.62 48.18 Ecuador - Equateur 892 382 1 274 892 382 1 274 100.00 100.00 100.00 Guyana ........ 96 36 132 84 34 118 87.50 94.44 89.39 Haiti - Ha"iti ..... 220 532 752 139 393 532 63.18 73.87 70.74 Jamaica - Jama"ique 157 46 203 7 4 11 4.46 8.70 5.42 Paraguay ... 2 140 955 3 095 1 061 193 1 254 49.58 20.21 40.52 Peru - Perou 9 6 15 0 0 0 0.00 0.00 0.00 Suriname. 194 106 300 154 96 250 79.38 90.57 83.33 Uruguay ... 233 60 293 200 38 238 85.84 63.33 81.23 Americas - Ameriques . 51 390 35 637 87 027 17 917 10 171 28088 34.86 28.54 32.28 Afghanistan ....... 406 370 776 145 153 298 35.71 41.35 38.40 Bangladesh ....... 6 581 6 753 13 334 3858 1 814 5 672 58.62 26.86 42.54 Bhutan - Bhoutan ... 337 78 415 294 53 347 87.24 67.95 83.61 Cambodia - Cambodge 1 109 141 1 250 1 109 141 1 250 100.00 100.00 100.00 China • - Chine• ... 1 390 152 1 542 1 338 96 1 434 96.26 63.16 93.00 India - lnde . . . . . . 101 546 209 292 310 838 48 297 75 622 123 919 47.56 36.13 39.87 Indonesia - lndonesie 11 049 11 119 22 168 5493 1 313 6806 49.71 11.81 30.70 Myanmar .... 536 1 140 1 676 510 66 576 95.15 5.79 34.37 Nepal - Nepal ..... 5 068 2 653 7 721 3 277 859 4136 64.66 32.38 53.37 Pakistan ........ 8429 2 654 11 083 2 682 500 3182 31.82 18.84 28.71 Philippines ....... 595 353 948 535 117 652 89.92 33.14 68.78 Republic of Korea - Republique de Coree ....... 4 031 2 414 6445 2 242 1 123 3 365 55.62 46.52 52.21 Sri Lanka ........ 794 1 859 2 653 794 1 859 2 653 100.00 100.00 100.00 Thailand - Tha'ilande . 15 088 5844 20 932 8 611 4 772 13 383 57.07 81.66 63.94 Asia - Asie .... 156 959 244822 401 781 79 185 88488 167 673 50.44 36.14 41.73 France (DOM-TOM) 290 23 313 0 0 0 0.00 0.00 0.00 Turkey - Turquie 878 56 934 546 33 579 62.19 58.93 61.99 Europe b ..... 1 168 79 1 247 546 33 579 46.75 41.77 46.43 Papua New Guinea - Papouasie- Nouvelle-Guinee ....... 25 5 30 6 1 7 24.00 20.00 23.33 West Samoa - Samoa occidental 52 0 52 52 0 52 100.00 0.00 100.00 Oceania - Oceanie 77 5 82 58 59 75.32 20.00 71.95 Total ILEP . .... 308 639 459 367 768 706 136 762 133 854 270 616 44.31 29.14 35.20 • The statistics from China do not include the following data from Taiwan Province: 755 patients on chemotherapy (506 MB and 249 PB); 443 patients receiving MDT (359 MB and 84 PB) - Les statistiques de la Chine ne comprennent pas les donnees suivantes concernant la Province de Taiwan: 755 patients traites par chimiotherapie (506 MB et 249 PB); 443 patients sous PCT (359 MB et 84 PB). b Includes French overseas departments and territories - Y compris les d0partements et territoires franc;ais d'outre-mer. paramedical workers to diagnose and treat leprosy cases and by asking nonmedical personnel, such as community leaders, to administer the monthly supervised doses in remote areas. These and other recommendations present a challenge to ILEP Mem- bers, medical personnel and ILEP partners in the field. W/d hlth statist. quart., 44 (19911 Monitoring projects in the field ILEP indicators The importance of monitoring the epidemiological and operational progress of leprosy control projects is emphasized by the selection of 17 indicators - 42 - which are calculated annually from the data collect- ed (Table 4). Seven of these indicators are used by project managers to monitor case-detection activities and the prevalence of leprosy. Another 10 indicators monitor the operational procedures associated with MDT. Whilst these indicators are useful for any field project carrying out MDT, they are most appropriate to vertical programmes with good data-collection systems. Computerized recording and reporting systems Those projects in the field with efficient infrastruc- tures are increasingly making use of modern tech- nology in the recording and reporting of patient data. A number of customized software packages have been developed specifically for the recording of data on leprosy patients. Such packages are cur- rently in use in India, Malawi and the United Re- public of Tanzania, amongst others. ILEP has pro- moted the use in the field of the WHO-developed ILOMSLEP system (7). These computerized systems provide not only for the maintenance of statistical data on patients, but also allow for the monitoring of progress through the calculation of indicators. Pioneering new approaches and new developments Integration and combined activities In most countries where ILEP Members are involved, leprosy-control activities were started as vertical pro- grammes. Since the introduction of MDT and the subsequent dramatic drop in patient case load, lep- rosy activities are gradually being integrated into the general health services. In general, it is felt that integration is the most cost-effective way to control leprosy. Components of the traditional v_ertical pro- grammes, such as supply of drugs and supervision, remain specialized. For operational reasons, vertical leprosy-control pro- grammes are often combined with tuberculosis ac- tivities, especially in Africa. ILEP Members are active in nationwide leprosy-tuberculosis programmes in countries (e.g. Guinea, Kenya, Paraguay, United Republic of Tanzania). More and more projects supported by ILEP Members have to take into account the impact of HIV infection and to take the appropriate action with regard to leprosy activities. This has been the case in central Africa. The ILEP Medical Commission has recom- mended that, in all projects, detailed clinical notes should be kept on any leprosy cases with a con- current HIV infection, in order to improve our under- standing of the situation. Urban programmes ILEP Members have been instrumental in promoting and supporting the development of urban pro- grammes in endemic countries. The mobility of the population in large cities, combined with the lack of community spirit and strong social stigma attached to leprosy, necessitate a special approach for run- TABLE 4. ILEP ANNUAL INDICATORS TABLEAU 4. INDICATEURS ANNUELS DE L'ILEP Indicators for leprosy-control activities 1. Prevalence rate of registered cases for chemotherapy 2. Prevalence rate of all registered cases (chemotherapy + surveillance+ care) 3. Case-detection rate of all patients (adults+ children) 4. Case-detection rate of children only 5. Proportion of MB cases among newly-detected cases 6. Proportion of children (0-14) among newly-detected cases 7. Proportion of disabled among newly-detected cases Indicators for MDT treatment and follow-up 8. Proportion of all new cases smeared 9. Proportion of MB cases on MDT smeared 10. Proportion of MB cases on MDT 11. Proportion of PB cases on MDT 12. Proportion of MB cases on regular MDT treatment at the end of the year 13. Proportion of MB cases who have completed MDT treat- ment as prescribed 14. Proportion of PB cases who have completed MDT treat- ment as prescribed 15. Proportion of MB cases under surveillance after MDT examined clinically 16. Proportion of PB cases under surveillance after MDT examined clinically 17. Proportion of MB cases under surveillance after MDT smeared lndicateurs pour Jes activites de Jutte antilepreuse 1. Taux de prevalence des cas enregistres en vue d'une chimiotherapie 2. Taux de prevalence de !'ensemble des cas enregistres (chimiotherapie +surveillance+ so ins) 3. Taux de detection pour !'ensemble des patients (adultes +enfants) 4. Taux de depistage des cas pour les enfants seulement 5. Proportion des cas MB parmi les nouveaux cas depistes 6. Proportion des enfants (0-14 ans) parmi les nouveaux cas depistes 7. Proportion des handicapes parmi les nouveaux cas depistes lndicateurs pour le traitement par PCT et le suivi 8. Proportion de !'ensemble des nouveaux cas ayant subi un frottis 9. Proportion des cas MB sous PCT ayant subi un frottis 10. Proportion des cas MB sous PCT 11. Proportion des cas PB sous PCT 12. Proportion des cas MB sous traitement PCT regulier a la fin de l'annee 13. Proportion des cas MB ayant acheve leur traitement PCT tel que prescrit 14. Proportion des cas PB ayant acheve leur traitement PCT tel que prescrit 15. Proportion des cas MB sous surveillance apres PCT examines cliniquement 16. Proportion des cas PB sous surveillance apres PCT examines cliniquement 17. Proportion des cas MB sous surveillance apres PCT ayantsubi un frottis Rapp. trimest. statist. sanit. mond., 44 ( 19911 - 43 - ning leprosy-control activities. Urban leprosy-control programmes make use of available facilities and involve all the peripheral health workers. Special attention is placed on the tracing of patients amongst the migrant population. Intensive health- education programmes, making use of existing media, often support the leprosy-control pro- grammes. Successful urban programmes are runn- ing in many Indian cities (Bombay, Calcutta, Madras), in many other Asian cities (Karachi, Manila), in Africa (Addis Ababa, Bamako, Nairobi), and also in South America (Bogota, Rio de Janeiro). Social rehabilitation ILEP Members, for historical and humanitarian reasons, have always shown a keen interest in the rehabilitation of leprosy patients, their reintegration into the community, and economic and social sup- port to their families. Member associations provide a service which the governments very often cannot undertake, and because of their flexibility they can experiment with innovative programmes. Physical rehabilitation In 1988, approximately 50% of treatment/control pro- jects supported by ILEP Members were providing protective footwear to leprosy patients with anaes- thetic feet. In many countries, like Colombia, Senegal and the United Republic of Tanzania, this service is organized at national level. Reconstructive surgery was performed in 26% of projects and eye care/ophthalmology services were available in 40%. Prevention of disabilities In recent years, several ILEP Members have taken the lead in placing greater emphasis on the preven- tion of disabilities within leprosy-control pro- grammes. Procedures must be devised for retaining contact with those patients who are released from control but who still require attention due to sensory loss or nerve damage. A particular initiative within ILEP to promote greater awareness of disability prevention is the Joint Project on Prevention of Sole Wounds. In 27 leprosy projects, two cohorts of patients - 25 with sensory loss in the foot but as yet no wounds and 25 with a history of wounds - are being followed over a 3-year period to test the impact of a systematic approach to foot care by staff and patients (8). Support activities Training ILEP Members' support for training activities is oriented towards leprosy field projects, emphasis being placed on the training of leprosy workers, particularly in MDT. Every field project supported by an ILEP Member has the opportunity each year to request funds for staff training. They are required to report on those training activities carried out in an appendix to the ILEP annual reporting form. Nine international leprosy training centres are cur- rently sponsored by ILEP associations. Bursaries are available to field staff for study at these institutions. Wld hlth statist. quart., 44 (1991) ILEP produces an annual training catalogue giving information on the courses available at these centres (9). The ILEP Medical Commission training discipline is currently organizing a series of workshops to "train the trainers" from these centres, so that new teaching methods and technologies can be passed on. Recent emphasis has been placed on assisting medi- cal and paramedical schools in leprosy-endemic countries in Africa to incorporate leprosy training into their curricula. A successful innovation has been the setting up of TALMILEP (teaching and learning materials in lep- rosy), an ILEP joint project which coordinates the production, assessment and distribution of leprosy teaching and learning materials (10). Scientific research Most ILEP Members spend some proportion of their income on the support of leprosy research activities; for some, this is the main focus of their work. In 1988, nearly US$ 6 million were used to finance short-term applied and basic leprosy research pro- jects and also institutions engaged in multi- disciplinary leprosy research. The proportion of the total funds of the Federation allocated to research has remained steady, at an annual rate of ap- proximately 10% since 1985. Fig. 4 illustrates support for different ILEP research categories in 1988. Whilst it is difficult in some cases to classify individual projects under just one cat- egory, Fig. 4 nevertheless gives some impression of the overall pattern of research funding. In 1988, the ILEP Medical Commission, with the assistance of invited scientific experts, identified a list of research priorities for the Federation. A high priority was given to applied research because of its direct impact on leprosy field work. ILEP associ- ations and their partners in the field are particularly well placed to carry out multicentred field research trials. Examples of applied research currently sponsored by ILEP associations include the trial of a potential leprosy vaccine in Malawi, an operational research study on the implementation of MDT in Ethiopia, clinical trials of new antibacterial treatment regimens and research aimed at preventing sole wounds in patients with insensitive feet. Basic re- search sponsored by ILEP Members is carried out in leprosy-endemic and nonendemic countries. The Medical Commission also plays a role in stimulating the development of new research projects,: and a multicentre study on the treatment of reversal reac- tions in borderline patients is currently being de- veloped. An ILEP International Research Advisory Panel is being set up to provide independent peer review of project applications and project evaluation on re- quest. Annual reports are obtained from each re- search project, information from which is published in the annual ILEP Directory of research (11). This coordination document also lists research cooper- ation with the WHO, TDR, IMMLEP and THELEP research programmes as well as collaboration with ILEP-sponsored field projects and any academic re- search institutions. The exchange of scientific information on leprosy is promoted through the sponsorship of scientific con- - 44 - FIG.4 DISTRIBUTION OF ILEP GRANTS FOR LEPROSY RESEARCH, 1988• -;;;- "O c: :Jl ::, 0 2 "' (/) :::, 1500 1000 Applied research projects Basic research projects Research institutions Support services ' LEP CTRLJEPID- Leprosy control/epidemiology M . leprae - Provision of M. leprae Drug develop. - Drug development and experimental chemotherapy. gresses, notably the International Leprosy Associa- tion (ILA) congresses, in addition to 8 scientific journals which specialize in publishing papers on leprosy. Conclusion Thanks to their flexibility, their sense of innovation and their commitment to the worldwide anti-leprosy campaign, ILEP Members are well placed to meet the challenge of making MDT available to all leprosy patients by the year 2000. This goal necessitates the extension of MDT to reach all the estimated 10 million leprosy sufferers worldwide, by first iden- tifying the gaps in coverage so that the resources available may be focused where they are most need- ed . In addition, the basic requirements for the intro- duction of MDT in field projects must be reassessed in order to facilitate its implementation. ILEP Mem- bers will continue to support field activities which focus on the prevention of disabilities and the care and follow-up of post-MDT patients. It is only through a good effective collaboration between government health services, field pro- grammes and NGOs involved in leprosy that MDT for all leprosy patients by the year 2000 can be achieved. SUMMARY The International Federation of Anti-leprosy As- sociations (ILEP) founded in 1966, consists of 22 autonomous nongovernmental organizations raising funds from the general public in the North for anti-leprosy work in the South . ILEP Member associations support over 800 field projects in 92 countries, in addition to over 130 research and other projects with a total annual expenditure of about US$ 60 million. 72% of the resources are spent on leprosy-control activities, 12% on training, 10% on research and 6% on socioeconomic activities. About 55% of resources are devoted to activities of national/regional leprosy programmes. ILEP-sup- ported projects had detected over 100 OOO patients in 1988. ILEP Member associations introduced WHO- recommended multidrug therapy (MDT) quite early, and the coverage for MDT in ILEP-supported projects has increased from 8% in 1984 to 35% in 1988 (271 OOO patients in 1989 out of 769 OOO on treat- ment). ILEP Member associations are currently sup- porting approaches towards integration of leprosy control with other services, urban leprosy pro- grammes and social and physical rehabilitation. Thanks to their flexibility, their sense of innovation and their commitment to the worldwide anti -leprosy campaign, ILEP Members are well placed to meet the challenge of making MDT available to all leprosy patients by the year 2000. Rapp. trimest. statist. sanit. mond., 44 (1991 ) - 45 - RESUME Activites de lutte antilepreuse de la Federation internationale des associations contre la lepre La Federation internationale des associations contre la lepre (ILEP), fondee en 1966, se compose de 22 organisations non gouvernementales autonomes qui recueillent des fonds aupres du grand public dans les pays du Nord pour le travail contre la lepre dans les pays du Sud. Les associations membres de l'ILEP subviennent a plus de 800 projets sur le ter- rain dans 92 pays, auxquels viennent s'ajouter plus de 130 projets de recherche ou autres totalisant une depense annuelle de quelque US$ 60 millions. 72% des ressources sont attribuees aux activites de lutte antilepreuse, 12% a la formation , 10% a la recherche et 6% a des activites socio-economiques. Environ 55% des ressources sont consacrees aux activites des programmes nationaux ou regionaux de lutte antilepreuse. Les projets soutenus par l'ILEP ont permis de detecter plus de 100 OOO cas en 1988. Les associations membres de l'ILEP ont introduit tres tot la polychimiotherapie (PCT) recommandee par l'OMS, et la couverture de cette therapie dans les projets de l' ILEP est passee de 8% en 1984 a 35% en 1988 (271 OOO patients en 1989 sur 769 OOO traites) . Les associations membres de l'ILEP soutiennent aujourd'hui les approches visant a !'integration de la lutte antilepreuse avec d'autres services, les pro- grammes de lutte antilepreuse dans les com- munautes urbaines et la readaptation sociale et physique des patients. Grace a leur flexibilite, leur sens de !'innovation et leur engagement dans la campagne mondiale contre la lepre, les membres de l'ILEP sont bien places pour relever le defi consistant a assurer un traitement polychimiotherapeutique a tous les lepreux d'ici l'an 2000. FIG.4 1500 "' i I "' U) :::, 1000 REPARTITION DES FONDS DE L'ILEP POUR LA RECHERCHE SUR LA LEPRE, 1988" Projets de recherche appliquee Projets de recherche fondamentale Institutions de recherche • LEP CTRUEPID - Lutte contre Ja Jepre/epidemiologie/M. leprae - Fourniture de M. /eprae Mise au point des medicaments- Mise au point des medicaments et chimiotherapie experimentale. Wld hlth statist. quart. , 44 (1991 ) Services d'appui - 46 - REFERENCES- REFERENCES 1. INTERNATIONAL FEDERATION OF ANTI-LEPROSY ASSOCIA- TIONS. Fighting leprosy together. London, ILEP, 1988. FEDERATION INTERNATIONALE DES ASSOCIATIONS CONTRE LA LEPRE. Unis contre la lepre. Landres, ILEP, 1988. 2. INTERNATIONAL FEDERATION OF ANTI-LEPROSY ASSOCIA- TIONS. ILEP statistics 1988: a global summary of Members' support for anti-leprosy activities. London, ILEP, 1988. 3. INTERNATIONAL FEDERATION OF ANTI-LEPROSY ASSOCIA- TIONS. ILEP Directory 1988 of support given by Member associations to field projects. London, ILEP, 1988. (3 volumes). 4. INTERNATIONAL FEDERATION OF ANTI-LEPROSY ASSOCIA- TIONS. The introduction of multidrug therapy for leprosy. London, ILEP, 1984. (Second edition). 5. CATHOLIC UNIVERSITY OF LOUVAIN. Global evaluation of the introduction of multidrug therapy. Leprosy epidemiological bulletin, 4: January (1990). 6. Basic requirements for implementation of multi- drug therapy. ILEP medical bulletin, 1: July (1990). 7. LECHAT, M. F. ET AL. OMSLEP: recording and reporting system for leprosy patients. Brussels, Catholic University of Louvain, Epidemiology Unit, 1987. (Third edition). 8. THE LEPROSY MISSION INTERNATIONAL. Prevention of sole wounds. London, The Leprosy Mission International, 1987. 9. INTERNATIONAL FEDERATION OF ANTI-LEPROSY ASSOCIA- TIONS. ILEP catalogue on training 1991. London, ILEP, 1990. 10. Teaching and learning material in leprosy. Wurzburg, TALMILEP, 1988. 11. INTERNATIONAL FEDERATION OF ANTI-LEPROSY ASSOCIA- TIONS. ILEP Directory 1988 of support given by Member associations to research projects. London, ILEP, 1989. Rapp. trimest. statist. sanit. mond., 44 (19911 WORLD HEALTH ORGANIZATION PUBLICATIONS NEW BOOK ANNOUNCEMENT World Health Statistics Annual 1990 1991, xxiv + 423 pages [bilingual English and French] ISBN 92 4 067905 7 Sw.fr. 90.-/US $81.00 In developing countries: Sw.fr. 63.- 0rder no. 0179000 The World Health Statistics Annual presents global statistical information designed to pro- vide both country and global overviews of changing trends in health status and in causes of death and morbidity. Statistics, which are sub- mitted to WHO by national health and statistical offices, are critically assessed in an effort to help countries identify health problems and inter- pret changes over time. In keeping with editorial policy, the 1990 edition opens with a detailed analysis of global data on a selection of special topics. 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Tables in the third section summarize the demo- graphic situation of countries in terms of those parameters likely to be of greatest relevance for health management. The final and most exten- sive section consists of a series of tabular statis- tics on causes of death, by sex and age, for a large number of countries and territories. ORDER FORM O Please send me __ copy/ies of World Health Statistics Annual 1990 at Sw.fr. 90.-/US $81.00 In developing countries: Sw.fr. 63.- (0179000) Name Address O Payment enclosed O Please charge to my credit card O Visa OAmerican Express O Eurocard/Mastercard/ Access Card number Expiry date Date of order Signatum W H O • D i s t r i b u t i o n a n d S a I e s • 1 2 1 1 G e n e v a 27 • S w i t z e r I a n d O R GAN IS AT I O N M O N D I ALE D E LA SANT E VIENT DE PARAITRE Annuaire de statistiques sanitaires mondiales 1990 Aper~u mondial. Statlstlques internationales sur les causes d'incapacite. Tables de survie et causes de deces Organisation mondiale de la Sante, 1991 xxiv + 423 pages, 8 planches couleur (Anglais/Frani;ais) ISBN 92 4 067905 7 Fr.s. 90.-- Prix dans les pays en developpement: Fr.s. 63.-- N" de commande 0179000 L'Annuaire de Statistiques sanitaires mondiales contient des informations statistiques corn;:ues de maniere a donner une idee de !'evolution des tendances de la situation sanitaire et des causes de mortalite tant dans les pays qu'a l'echelle mondiale. Ces statistiques, adressees a l'OMS par les services nationaux de sante et de statistique, sont soumises a un examen critique pour aider les pays a identifier leurs problemes de sante et a interpreter les change- ments qu'ils observent. Conformement a la politique adoptee pour cette publication, !'edition 1990 debute par !'analyse detaillee de donnees mondiales sur une serie de sujets particuliers. 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Mouvement de la population et tables de survic, evaluation de la Strategie mondialc de la sante pour tous, causes de deces ( I seul volume). 692 pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fr.,. 90.- 1987, Mouvement de la population et tables de survie, santC et soins bucco-dentaires, causes de dCCCs ( I scul volume), 455 pages . . . . . Fr. 5.. 90.- 1988, Mouvcment de la population et tables de survic, la situation des professions de sante dans les annees 80, causes de dCcCs ( I seul volume). 513 page,................................. Fr. s. 90.- 1989, Mouvement de la population et tables de survie, le Projet MONICA de L 'OMS. causes de deci:s ( L seul volume), 443 pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fr. s. 90.- PROGRESS IN LEPROSY CONTROL THROUGH MULTIDRUG THERAPY In recent years leprosy control and the resulting world situation of the disease have been undergoing important changes for the better. This is due mainly to the introduction of the WHO-recommended multidrug therapy (MDT) in disease control and the increasing political commitment to and resources for leprosy control. Over the past five years, a reduction of 30% in the number of registered cases of leprosy has been observed with the figures for 1990 being about 3.7 million. In spite of this progress, several problems remain. MDT coverage is still quite low in 40% of the endemic countries. There are considerable uncertainties about the proportion of undetected cases as those registered do not fully reflect the magnitude of the problem. Further, MDT does not directly address the question of prevention of disabilities in leprosy which is a major concern in the disease. It is important that this issue of the Quarterly highlights not only the major problem areas in leprosy control, such as those found in many parts of Africa, but also the success stories, in this case those of India and Zambia. The massive MDT operation in India aims to reach most leprosy patients within the shortest possible period of time, and the results so far are heartening thanks to the strong political commitment combined with the large mobilization of resources. The Zambian success demonstrates the effectiveness for leprosy work of integrated programmes supported by specialized services as well as the relevance of community-based rehabilitation. A major contributing factor to the current progress in recent years is the participation of nongovernmental organizations (NGOs), at both national and international levels. In some countries, national NGOs have provided critical inputs to ensure political commitment and increased priority for leprosy. However, international NGOs, such as the Member associations of the International Federation of Anti-leprosy Associations (ILEP), have played a key role in making available to countries substantial quantities of resources: in some instances, leprosy control could not have been possible without such support. The future for leprosy control, and even the elimination of the disease as a public health problem, appears bright provided national commitments continue to be strengthened and sufficient resources are made available to ensure increasing coverage of MDT. WHO has played and continues to play a key role in technical collaboration with its Member States as well as in the mobilization and coordination of resources. PROGRES DANS LA LUTTE ANTILEPREUSE PAR LA POLYCHIMIOTHERAPIE Ces dernieres annees, la lutte antilepreuse a fait d'importants progres et, de ce fait, la situation de la maladie dans le monde s'est notablement amelioree. Cela est du principalement a !'introduction de la polychimiotherapie (PCT) recommandee par l'OMS pour )utter contre Ja maladie, a un engagement politique accru ainsi qu'a une augmentation des ressources en faveur de la lutte antilepreuse. Ces cinq dernieres annees, une reduction de 30% du nombre de cas enregistres de lepre a ete observee, le nombre de cas pour 1990 se situant aux alentours de 3,7 millions. Malgre ces progres, plusieurs problemes demeurent. La couverture par la PCT est encore relativement faible dans 40% des pays d'endemie. Le doute subsiste quanta la proportion de cas non deceles car les cas enregistres ne refletent pas entierement l'ampleur du probleme. Par ailleurs, la polychimiotherapie ne resout pas directement la question de la prevention des incapacites, preoccupation essentielle dans cette maladie. Le present numero du Trimestriel met l 'accent sur Jes grandes zones a problemes en matiere de lutte antilepreuse - comme on trouve dans de nombreuses regions d' Afrique - mais ii souligne aussi les succes remportes, en Inde et en Zambie notamment, et cela est important. La campagne massive de PCT en Inde vise a atteindre la plupart des patients en un minimum de temps et les resultats ont ete encourageants jusqu'ici grace a une forte volonte politique alliee a une importante mobilisation de ressources. La reussite zambienne demontre 1'efficacite, dans l'action antilepreuse, de programmes integres soutenus par des services specialises ainsi que !'importance de la readaptation au sein de la communaute. La participation d'organisations non gouvernementales (ONG),.aux niveaux national et international, a joue un role de premier plan dans les progres enregistres ces dernieres annees. Dans certains pays, des ONG nationales ont contribue de maniere determinante a assurer !'engagement politique et a faire accorder une plus grande priorite a la lepre. Mais ce sont des ONG internationales telles que les Associations membres de la Federation internationale des associations de lutte antilepreuse qui en ont ete les principaux acteurs en mettant a la disposition des pays des ressources importantes: dans certains cas, la lutte antilepreuse n 'aurait pas ete possible sans leur appui. La lutte antilepreuse, voire )'elimination de la maladie en tant que probleme de sante publique, se presentent sous les meilleurs auspices, pour peu que !'engagement national s'accentue et que des ressources suffisantes permettent d'accroitre la couverture par la PCT. L'OMS a joue et continue de jouer un role cle dans la collaboration technique avec les Etats Membres ainsi que dans la mobilisation et la coordination des ressources.
World Health Organization (WHO) · Journal articles
Progress in leprosy control through multidrug therapy = Progrès dans la lutte antilépreuse par la polychimiothérapie [full issue]
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