active case finding for leprosy elimination · leprosy: key aspects mostly affects rural poor...

1 |Scoping Meeting TB - 31 May 2011, Geneva

Active case finding for leprosy

elimination

D. Daumerie WHO/NTD


Leprosy: key aspects

Mostly affects rural poor

Natural history and transmission poorly known

Long or very long incubation period

Chronic disease with acute episodes (dermatological and neurological)

Several types and classifications. WHO classification consists of 2 groups PB and MB


In most situations diagnosis is clinical (anaesthetic skin patches, classification based on number of patches)

Skin smear examination difficult in most settings. Proportion of skin smear positive cases very low, even among MB cases

Epidemiology of the disease is not influenced by the HIV situation

Treatment with MDT is safe, effective and free of cost to the patient.

So far, no resistance to MDT

Leprosy: key aspects (2)


Simplified diagnosis and treatment


Elimination concept and introduction of

intensive active case finding

In 1991 leprosy elimination as a public health problem: below 1 per 10 000 population.

At that time reported prevalence was 5.4 million patients, estimated prevalence 11 million and coverage with MDT below 10%. Incidence was unknown.

Leprosy elimination campaigns (LECs) were introduced in 1995 with the aim of diagnosing and treating the large number of "hidden" cases in at risk communities.

Hidden cases were considered to be the main source of transmission.


Main steps in LECs

• Development and local adaptations of guidelines for LECs implementation

• Identification of populations (or areas) that would benefit from LECs

• Information (decision-makers, health workers, community)

• Rapid training of volunteers and/or health workers for "identification of suspects"

• Referral system for diagnostic confirmation and treatment

• Recording, monitoring and evaluation


Key elements of LEC

Community mobilization Mass media campaigns

Active case finding Treatment and recordingReferral for confirmation

Training


Main achievements with LECsRef. Weekly Epidemiological Record 1999, 74, 329-336

LECs actively implemented in 24 high endemic countries.

India and Brazil covered large populations. BBC world

service did intensive media campaigns in these 2 countries

In 4 years, 500 000 health workers and 300 000 volunteers

have been trained.

More than one billion persons have been reached, and more

than half million cases have been confirmed.


Salient features of LECs

Highly variable outcomes, mostly depending on the prevailing situation and infrastructure.

Main difficulties are logistical (organizing proper referral system, treatment supply at the right place)

Average cost per diagnosed patient: $97 (range 1 to 1,300).


Global impact of LECs

The aim of detecting "hidden" cases and thereby reduce transmission has been achieved

Access to diagnosis and treatment has dramatically improved, especially for difficult-to-reach populations

Proper case management and adherence to treatment remain the main challenges


Main limitations of LECs(Ref Leprosy Review, Vol 70 No 4)

Active case-finding hinders self reporting and integration

Unclear impact on stigma and discrimination

Rapid training leads to overdiagnosis and weak case management

Large number of cases could still be missed (LECs versus total population surveys)

Limited evidence on long term impact on the transmission of the disease

Lack of clarity on how frequently LECs should be repeated

Key issue: cost effectiveness, especially in low prevalence areas


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Lessons learnt

Proactive strategies to improve access to early diagnosis and treatment are essential, and beneficial

The absence of "ideal" screening and diagnostic tools should not be an obstacle

Research and modelling should "accompany" implementation

Technical guidelines should be adapted to local situation

Disease specific active case finding is difficult to justify

Information to and participation of target population is crucial

Interventions should be free of costs for the target population, treatment should be regularly available


Thank you

active case finding for leprosy elimination · leprosy: key aspects mostly affects rural poor...

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