WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
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ORGANISATION MONDIALE DE LA SANTE
REGIONAL COMMITTEE Forty-sixth session Manila 11-15 September 1995
WPRlRC46114 19 June 1995 ORIGINAL: ENGLISH
Provisional agenda item 15
LEPROSY
The Forty-fourth World Health Assembly, in May 1991, adopted resolution WHA44.9 on the elimination of leprosy as a public health problem in the world by the year 2000. Among the 36 countries and areas of the Western Pacific Region, 18 have reached the elimination target of less than one case per 10000 population. Four
countries in the Region still have high prevalence rates, and two have remaining "pockets" of leprosy in areas which are difficult to access. The regional strategy is addressing these issues. In 1994, 39911 registered cases and 12694 new cases were reported in the Region. Almost all cases in the Region are treated with multidrug therapy. As a result of this, the overall prevalence rate in the Region dropped from 1.7 per 10 000 popUlation in 1986 to 0.25 in 1994. Government support and commitment to the elimination of leprosy is strong, but must be sustained, particularly in the countries which still have cases. Member States are urged to intensify leprosy control activities with appropriate funding where the disease is still endemic, and to maintain the awareness both of the general public and the health sector in countries and areas where leprosy is no longer a public health problem.
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1. INTRODUCTION
The Forty-fourth World Health Assembly, in May 1991, adopted resolution WHA44.9 on the elimination of leprosy in the world by the year 2000. The resolution declares WHO's commitment to promote the use of all control measures to attain the global elimination of leprosy as a public health problem. The elimination of leprosy is defined as the reduction of prevalence to a level below one case per \0 000 population. There are 36 countries andareas in the Western Pacific Region. These may be divided into four groups according to their leprosy situation. Group I contains countries with very few cases or no cases of leprosy. These countries are Australia, Japan, Mongolia and New Zealand. Group 2 comprises 15 countries and areas which have recently reached the elimination target of less than one case per 10 000 population. These are: Brunei Darussalam, China, Cook Islands, Fiji, French Polynesia, Hong Kong, the Republic of Korea, Macao, Malaysia, Niue, Singapore, Solomon Islands, Tonga, Vanuatu, and Wallis and Futuna. Group 3 comprises 13 countries and areas which have not yet reached the elimination target but, with sustained efforts, are close to reaching it during the next three years. These are: American Samoa, Guam, Kiribati, the Lao People's Democratic Republic, the Northern Mariana Islands, the Marshall Islands, Nauru, New Caledonia, Palau, Samoa, Tokelau, Tuvalu and Viet Nam. Among these, five countries and areas have less than ten cases. Group 4 comprises the countries which still have high prevalence rates. These are Cambodia, the Federated States of Micronesia, Papua New Guinea and the Philippines. -
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2. PRESENT EPIDEMIOLOGICAL SITUATION
In 1994, 39911 registered cases of leprosy were reported, of which 12694 were new cases (Table I). Almost all cases (more than 95%) are treated with multidrug therapy.
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Table 1. Summary of essential indicators for leprosy, Western Pacific Region (latest available data as at May 1995)
Country American Samoa AustraJia*
Population (000) 50 17843 276 9000 I 200000 18 771 214 143 5812 123940 76 4591 18995 395 50 54 112 2 250 9 164 3463 2
Year 1993 1994 1993 1994 1994 1994 1994 1994 1993 1992 1989 1994 1994 1994 1993 1994 1994 1994
Prevalence (Reeistered cases) per IO 000 Number 21 10 3 2461 5655 0 39 II 24 47 768 46 967 I 823 4.20 0.00 0.10 2.73 004 0.00 0.50 0.51 1.67 0.08 0.06 6.00 2.10 0.95 032 1.80 148 25.89
Detection (New cases) per to 000 Number 4 0.80
... 3 1644 2096 0 9 9 4 20 0 17 304 330 I I 8 95
... 0.10 1.82 0.01 0.00 0.11 0.42 0.27 0.03 0.00 2.23 0.66 0.17 0.02 0.20 1.48 8.48
Brunei DarussalamCambodia
China·
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Cook Islands'
FijiFrench PolynesiaGuam Hong Kong' Japan'
Kiribati Lao People's Democratic Republic Malaysia-
Macao· Mariana Islands. Northern·· Marshalilslands" Micronesia, Federated States of Mongolia
13 9 8 290
... 1994 1993 1994 1994 1994 1994 1994 1994 1994 1993 1994 1992 1993 1994 1994 1994 1994
... 8 35 I 0 12 2 167 16486 1209 20 303 35 I I 3 16 7419 0 39911
... 8.88 1.90 0.00 000 9.23 534 2.53 0.27 1.23 1.05 0.92 5.00 0.10 333 0.97 1.00 0.00 0.25
... 2 10 I 0 5 345 4450 113 10 24 9 I 0 3 3 3 173 0 12694
... 2.22 0.60 000 000 3.84 0.85 0.68 0.02 0.61 0.08 0.23
Nauru·· New Caledonia
Ne,..· Zealand· Niue· Palau Papua New Guinea Philippines Republic of Korea' Samoa Singapore Solomon Islands'
13 4056 65000 44553 162 2870 379 2 98 9 164 74008 20 I 579462
Tokelau·· Tonga·
SOC 0 3.33 0.18 042 0.00
Tuvalu·· Vanuatu· Viet Nam Wallis and Futuna'
TOTALS
0.08
... Data not available. *Country with less than I case per 10 000 population. "Country with less than 10 cases.
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The prevalence rate dropped from 1.7 per 10000 population in 1986 to 0.25 per 10 000 in 1994 (Figure 1). Over the same period, multidrug therapy coverage rose from 8.8% to more than 95%. Overall, using an average figure, the Region achieved the goal of elimination of leprosy in 1991, technically defined as less than one case per 10000. The average does not present a good picture of the actual situation. Only 18 countries have less than one case per 10 000 population. Even in these countries, there are pockets of high prevalence. China, for example, still has a few areas of high endemicity.
Figure 1. Leprosy prevalence rates and multidrug therapy coverage Western Pacific Region, 1983-1993
. ~ u l1li
g = ..... ~
1.8 1.6 1.4
a 1.2 Co.
::;: 1 "'.!! ~ So 0.8 .... c
11
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0.6 0.4
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a
0.2
o 83 84 85 86
100 90 80 70 60 50 40 30 20 10 0 87 88 89 90 91 92 93 94
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YEAR .....- Prevalance rate ___ Multidrug therap
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Looking at the case distribution (Figure 2), it is noticeable that China, the Philippines and Viet Nam, three of the largest countries of the Region, also account for a large number of cases compared to Cambodia and Papua New Guinea. When comparing rates, however, (Figure 3), it becomes obvious that some small countries also have a serious leprosy problem, like the Federated States of Micronesia (26 cases per 10000 population) and Papua New Guinea (5.3 cases per 10000 population).
Figure 2. Registered leprosy cases by country
Viet Nam 19% Others 9% Malaysia 5%
Western Pacific Region, 1994
Philippines 42%
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Cambodia 6%
China 14%
Papua New Guinea 5%
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Figure 3. Number of reported cases and prevalence rates for ten countries Western Pacific Region, 1994
Cambodia China Kiribati Lao P.D.A. Malaysia Micronesia, F.S. Papua New Guinea Philippines Solomon Islands Viet Nam 20 15 10
5
o
1"
5
10
15
20
25
30
II1II
No.ofcases (in 1ooos)
III
Prevalence rate (per 10000 population)
* target of 1 case per 10 000 population
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In 1989, the trend in leprosy prevalence rates started to show a marked decline (Figure 1). This was due to a combination of two factors: 1. shortened duration of treatment due to implementation of multidrug therapy: six months for
paucibacillary patients and two years for multibacillary patients (instead of five years and life-long treatment); and 2. reassessment of all registered cases before or during implementation of multidrug therapy;
this resulted in the release of many patients from treatment and also from the deletion of many patients from the registries (dead, migrated, etc). However, in some countries like Cambodia, the programme is expanding, resulting in increased awareness and case detection, and bringing about an increase in reported prevalence.
3. PROGRAMME ACTIVITIES
3.1
Regional strategy for the elimination ofleprosy The regional strategy is based on five main activities:
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I.
Extension of multidrug therapy to areas which are difficult to reach, using several
approaches, including community participation in patients' treatment, training of health workers, mobile supervisory teams, and health systems research on treatment management. 2. A special programme for selected countries and areas of high endemicity which includes
thorough evaluation of the situation, a specific plan of action, specific support and an innovative strategy for treatment. 3. Improvement of management by training leprosy workers, reinforcing in-service training, and
better planning and simplification of the information system. 4. Monitoring and evaluation of programme achievement using a simplified regional
information system for leprosy, organizing independent evaluation, periodic national programme assessment and regional workshops.
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5.
Planning of a rehabilitation programme
In
countries where control of leprosy is well
established. The International Conference on Leprosy Elimination in Hanoi, Viet Nam, in July 1994, attended by the 28 countries most endemic for leprosy in the world and funding agencies, provided support to the aims of the regional strategy, through the reaffirmation of the participants' commitment to the goal of eliminating leprosy as a public health problem by the year 2000.
3.2
Leprosy control activities Elimination of leprosy in the Pacific island countries and areas is being achieved by
strengthening leprosy control measures. Extra personnel are trained and regular assessment is made of the situation in 12 countries and areas. This is supported by the Pacific Leprosy Foundation. The WHO/PLF/SPC workshop on management of tuberculosis and leprosy elimination programmes in Suva, Fiji, in November 1994 warned countries not to slacken their guard in the light of initial successes, and recommended that international support to leprosy elimination should be further encouraged. Each country outlined a plan of action to sustain leprosy elimination or to reach the elimination goal according to their leprosy situation. Out of the four countries in the South Pacific targeted for leprosy elimination by 1995, three have already achieved the goal: Cook Islands, Fiji and Tonga. Samoa is likely to achieve elimination status by the end of 1995. Comprehensive evaluation of the multidrug therapy programme was carried out in China (15 provinces), Cook Islands, the Lao People's Democratic Republic and Malaysia. These activities were supported by the Sasakawa Memorial Health Foundation. Countries with high prevalence rates received special attention to strengthen their programmes. In Papua New Guinea, implementation of a detailed plan of action started in 1994. In Cambodia, a national leprosy control programme has been designed and implementation of a plan of action started in 1993. In the Federated States of Micronesia, a special action project aims to decrease the incidence of leprosy. In the Philippines, new policies and a new recording-reporting system have started.
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4. RESOURCE REQUIREMENTS
WHO works in close collaboration with many nongovernmental organizations which support national leprosy elimination programmes. In Cambodia, the Lao People's Democratic Republic,
Papua New Guinea and the Philippines, a coordination meeting is convened every year between the national leprosy programme manager, nongovernmental organizations and WHO, to discuss achievements, the plan of activities for the next year, and the related budgetary requirements. These coordination meetings have been instrumental in ensuring that the funds provided are effectively spent.
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In the Region, nine international nongovernmental organizations l give support directly to countries. In some countries, local nongovernmental organizations also support the national
programme. Almost US$5 million was given in 1993 for leprosy elimination and rehabilitation. Of this, approximately US$I.5 million was provided to four of the countries most endemic for leprosy (Cambodia, the Federated States of Micronesia, Papua New Guinea and the Philippines). During the next five years, intense efforts will be necessary in these countries. A major contributor to these efforts is the Japan Shipbuilding Industry Foundation (JSIF), which established a fund for drug procurement through WHO in 1995. In the other leprosy-endemic countries, the government or international nongovernmental organizations provide the necessary drugs, in collaboration with WHO.
5. CONSTRAINTS AND PROBLEMS
5.1
Surveillance Six essential indicators have been defined, and countries are requested to simplify their
recording and reporting system to report only these:
I
American Leprosy Mission, Amici di Raoul Follereau, Comite International de l'Ordre de Malte, Damicn Foundation Belgium,
German Leprosy Relief Association, Netherlands Leprosy Relief Association, Pacific Leprosy Foundation, Sasakaw. Memorial Health Foundation, The Leprosy Mission International.
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(I)
number of cases and prevalence rate;
2
(2)
number of new cases and detection rate;3 percentage of cases with disability among new cases; percentage of children among new cases; number of patients who completed treatment during the year; number of relapsed cases.
(3 )
(4) (5) (6)
5.2
Areas with limited access Many countries in the Region have are~_s
which are difficult to reach, and are generally poorly _
serviced by the health infrastructure. This limits access to patients and hinders the implementation of multidrug therapy.
5.3
Monitoring the patient During the course of the treatment, the patient can develop acute neuritis, an immunological
reaction which needs medical intervention. Patients living far from health services are not able to report to the doctor promptly and develop irreversible disability.
6. FUTURE ACTIVITIES
Monitoring of leprosy elimination will be reinforced through a better surveillance system and periodic in-depth evaluation of the leprosy control programme. A review of data for each country will be performed and published by the Regional Office, together with basic information on control programmes. A regional meeting for leprosy elimination will be convened in February 1996 with the objectives of: reviewing the leprosy situation in countries and areas in the Region with remaining cases; planning a four-year strategy of intervention for elimination of leprosy in all countries and
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2
All registered cases divided by population
) New case. divided by popUlation.
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areas in the Region; sustaining awareness of leprosy towards complete eradication of the disease in the next decades; and discussing a standard surveillance system for leprosy. Three thorough evaluations of the leprosy programme will be completed by mid-1996 in Cambodia, Papua New Guinea and the Philippines, to measure progress made under the new plan. Six priority countries have been identified for intensified activities: Cambodia, China, the Federated States of Micronesia, Papua New Guinea, the Philippines and Viet Nam. Strengthening national programmes and development of special actions for specific problems will be the main activities. For example, a special project will be implemented in a high plateau province in This will be done through encouraging
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Viet Nam, to address the problem of inaccessibility.
community participation in the programme, and delegation of responsibility for the treatment to the village health workers. Pacific island countries which have not reached the elimination goal will also be given particular attention.
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