leprosy elimination project status report 2003 · who leprosy elimination project: status report...

World Health OrganizationLeprosy Elimination Project

Status Report 2003

Draft

World Health Organization

Geneva 2004

Leprosy Elimination Group

Strategy Development and Monitoring for Eradication and Elimination (CEE)

Department of Control, Prevention and Eradication (CPE)

Programme on Communicable Diseases (CDS)

World Health Organization

CH-1211 Geneva 27

Telephone: +41 22 791 3919, Facsimile: +41 22 791 4850

Email: [email protected]

Internet: http://www.who.int/lep

© World Health Organization,2004This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes.

The views expressed in documents by named authors are solely the responsibility of those authors.

WHO Leprosy Elimination Project: Status Report 2003

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Table of Contents

Introduction......................................................................................................................... 7

The global leprosy situation................................................................................................ 8

Major endemic countries....................................................................................11 Brazil.................................................................................................................11 India....................................................................................................................13 Madagascar........................................................................................................18 Mozambique........................................................................................................19 Nepal................................................................................................................20 Tanzania...............................................................................................................21

MDT Drug Supply...........................................................................................................23 Trends in MDT drug supply................................................................................23 MDT procurement and supply................................................................................23 Buffer stock levels..............................................................................................24 Supply of loose clofazimine................................................................................25

Special Campaigns...................................................................................................... 25 Special Campaigns for elimination................................................................... 25 Achievements.........................................................................................27

Special Action Projects...................................................................................................29 Achievements......................................................................................... 29 Lessons learned............................................................................................. 31

UN Special Initiative.........................................................................................................32

Global Research.........................................................................................................33 Ongoing research efforts........................................................................... 33 Research opportunities.......................................................................... 33 Transmission.................................................................................... 33 Nerve Damage......................................................................................... 33 Research to improve integration.............................................................................. 33

Meeting of the Technical Advisory Group (TAG) in 2003...........................................34

Perspectives and Plan for 2004....................................................................................35

WHO activities for 2004...................................................................................................36 Summary of key activities to be undertaken by WHO............................................ 36

Annexes.....................................................................................................37 Annex 1: Leprosy Elimination Monitoring & Evaluation in India...........................37 Annex 2: MDT Drug Supply 2003 and Plans for 2004..........................................40


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Abbreviations used in the Text

AFRO WHORegionalOfficeforAfricaAMRO WHORegionalOfficefortheAmericasAMDT Accompanied MultiDrug TherapyBBC/WST BBC World Service TrustCBR Community-based rehabilitationDANLEP Danish Assisted National Leprosy Eradication Programme (India)EMRO WHORegionalOfficefortheEasternMediterraneanEURO WHORegionalOfficeforEuropeGIS Geographical Information SystemsGAEL Global Alliance for the Elimination of LeprosyIAS Indian Administrative ServicesIEC Information, Education and CommunicationILEP International Federation of Anti-Leprosy AssociationsLCU Leprosy Control Unit (India)LEC Leprosy Elimination CampaignsLEM Leprosy Elimination Monitoring MB Multibacillary leprosyMDT Multidrug Therapy (Clofazimine, Dapsone, Rifampicin)MLEC ModifiedLeprosyEliminationCampaign(India)NGO Non-governmental OrganizationNLEP National Leprosy Eradication Programme (India)PAHO Pan American Health OrganizationPB Paucibacillary leprosyPHC Primary Health Care POD Prevention of disabilitiesSAPEL Special Action Projects for the Elimination of LeprosySEARO WHORegionalOfficeforSouth-EastAsiaSSL Single skin Lesion PB leprosyTAG Technical Advisory GroupTDR Special Programme for Research and Training in Tropical DiseasesUNDP United Nations Development ProgrammeWHO World Health OrganizationWPRO WHORegionalOfficefortheWesternPacific

Glossary of some terms used in the text

Leprosy is predominately a disease of the poor, the underpriviledged and the marginalised. Some statistics used in the text to show the economic status of endemic countries may require some explanation. In the World Bank statistics shown in the country profiles, GNI per capita (formerly GNP per capita) is the gross national income, converted to U.S. dollars and divided by the midyear population. Official development assistance and net official aid record the actual international transfer by the donor of financial resources or of goods or services valued at the cost to the donor, less any repayments of loan principal during the same period. Aid per capita includes both ODA and official aid, and is calculated by dividing total aid by the midyear population estimate. For a more detailed explanation, see the World Bank website on http://www.worldbank.org/data/countrydata/countrydata.html

UNDP statistics are also used in the country profiles. The Human Development Index (HDI) is a summary measure of human development. It measures the average achievements in a country in three basic dimensions of human development: 1) A long and healthy life, as measured by life expectancy at birth; 2) Knowledge, as measured by the adult literacy rate (with two-thirds weight) and the combined primary, secondary and tertiary gross enrolment ratio (with one-third weight); 3) A decent standard of living, as measured by GDP per capita. The data on access to essential drugs are based on statistical estimates made by WHO country and regional offices and regional advisers and through the World Drug Situation Survey carried out in 1998-99. These estimates represent the best information available to the WHO Department of Essential Drugs and Medicines Policy to date and are currently being validated by WHO member states. The department assigns the estimates to four groupings: very low access (0-49%), low access (50-79%), medium access (80-94%) and good access (95-100%). These groupings, used here in presenting the data, are often employed by the WHO in interpreting the data, as the actual estimates may suggest a higher level of accuracy than the data afford. See the UNDP Human Development Report 2003, which can be downloaded at: http://www.undp.org/hdr2003.


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1. Announced at the 54th World Health Assembly in Geneva in May 2001. The elimination of leprosy as a public health problem isdefinedasthereductionoftheleprosyprevalenceatagivenpoint in time to a level below one case per 10,000 population, atthenationallevel.Thisdefinitionoftheeliminationofleprosyis used throughout this report.

The elimination of leprosy as a public health problem at the global level in 20001 was more than a major landmark of historical significance. It also permitted the adoption of a more differenti-ated approach to leprosy elimination, and focused international attention on national programmes with high levels of leprosy endemicity. The key question that remains is why some countries have been more successful than others in eliminating the disease.

There is clear evidence that the elimination strategy itself remains sound and effective: over the last 17 years, the global prevalence has fallen by almost 90%, and more than 13 million patients have been cured. Some 112 of the 122 countries considered endemic in 1985 had eliminated leprosy at the national level by the end of 2003. Leprosy now remains a public health problem in only 10 countries in Africa, Asia and Latin America.

Improved access to diagnosis and the widest possible availability of good quality MDT remain the cornerstones of the leprosy elimination strategy, and the best way of achieving this is the integration of leprosy services into the national primary health care system. WHO is fully committed to the integra-tion of leprosy services as a way to permanently ensure the widest possible treatment coverage and the raising of community awareness, both of the disease and its treatment. It is the only way of sustaining control efforts in the post-elimination phase.

The phasing out of all vertical programmes was planned for in WHO’s earliest formulation of a global elimination strategy, and it was recognised from the outset that countries would vary in their capacity to full implement the process within a reasonable time-span.

However, despite the challenges that still remain, we can be confident that the basic groundwork for integration has now been completed in most major endemic countries, with national and local authori-ties often very keen to assume the “ownership” and responsibility for leprosy elimination. WHO’s role in the short to medium term must be to facilitate this development process in terms of funding, providing technical advice, MDT drug supply and logistics, and global advocacy.

WHO continues to work closely with individual partners in the field, including national and interna-tional NGOs. Where their activities strengthen and facilitate the work and aspirations of the national programme, they remain a vital and dynamic ele-

Status of Elimination in 2003

• By the end of 2003, more than 13 million cases had been cured.

• Among newly detected cases reported withclassifications in2002,about13%were children (below the age of 15), 39% wereMBbasedontheclinicalclassifica-tion (more than 5 skin lesions), and just over 3% presented with grade 2 disability at the time of diagnosis.

• The numbers of relapses remain low, at less than one case per 1 000 patient per year.

• No drug resistance following MDT has yet been reported.

• The number of countries showing preva-lence rates above 1 per 10 000 population has fallen from 122 in 1985 to 10 by the end of 2003.

• There are fewer uncovered areas, includ-ingthosewhicharedifficulttoaccessorcontain refugee populations, though this still remains problematic in some areas.

• The gender imbalance has decreased significantly.

• An increasing number of countries are requesting WHO for a free supply of MDT drugs. WHO now provides close to 100% of global requirements.

• At the beginning of 2003, the number of leprosy patients in the world was around 534 000, as reported by 110 countries. About 621 000 new cases were detected during 2002.

ment of the elimination process.

This Status Report for 2003 provides an update on the progress made towards elimination over the past year, using the latest official statistics provided to WHO by the Ministries of Health concerned, and the key activities WHO plans to undertake during 2004. Annex 1 provides a summary of a key moni-toring and validation exercise carried out in India during 2003, while Annex 2 gives details of MDT shipments in 2003 and the planned shipments of MDT in 2004.

Introduction


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Greatly improved information systems now established in most endemic countries illustrate the substantial progress made so far in eliminat-ing leprosy as a public health problem, using MDT to tackle the disease. The number of cases regis-tered has been reduced by almost 90% since 1985, when MDT started being introduced into countries on a global scale - from around 5.4 million to less than 0.53 million at the beginning of 2003. Table 1 below shows the latest information on prevalence and detection of leprosy by WHO region at the beginning of 2003.

Global detection reached a peak of 804 000 in 1998, levelling off at around 750 000 for a number of years but falling to around 621,000 in 2002 (with 110 countries reporting). WHO attributes this to a number of factors, such as the intensified efforts of case detection, high transmission of the disease in certain areas, over-diagnosis or re-registration of previously treated cases, targets set for case detec-tion in some programmes, and leprosy elimination campaigns (about 50% of the cases are attributed to the wide scale introduction of the LECs).

At the end of 2003, 10 countries have not been able to reach the elimination target at the national level, and taken together, these countries still rep-resent the major part of the global burden of the disease. These are: Angola, Brazil, Central African

Table 1: Leprosy Situation as reported by 110 countries, at the beginning of 2003, by WHO region

Region RegisteredPrevalence atend of 2002

Cases detected during the year 2002

Africa 53 888 48 248

Americas 75 686 39 939

Eastern Mediterranean 7 899 4 665

South East Asia 385 458 520 632

WesternPacific 11 335 7 154

Europe 45 34

Total: 524 311 620 672

Table 2: Top endemic countries at the start of 2003

Region Registered cases at end of 2002 (rateper 10 000)

Cases detected during 2002(rate per 100 000)

India 344 377 (3.3) 473 658 (46.0)

Brazil 71 139 (4.1) 38 365 (22.3)

Madagascar 6 602 (4.0) 5 482 (33.4)

Mozambique 7 136 (3.6) 5 830 (29.1)

Nepal 7 291 (3.0) 13 830 (56.5)

Tanzania 7 063 (2.1) 6 497 (19.0)

Total: 443 608 (3.4) 543 662 (41.9)

Table 3: Number of new cases detected during 2001 and 2002 by WHO Region (latest available data)

Region Cases detected during the year

2001 2002

Africa 39 612 48 248

Americas 42 830 39 939

Eastern Mediterranean 4 758 4 665

South East Asia 668 658 520 632

WesternPacific 7 404 7 154

Europe 25 34

Total: 763 287 620 672Note: Europe data shown for 2001 is 2000 data.

The global leprosy situation

Republic, Congo, India, Liberia, Madagascar, Mozambique, Nepal and United Republic of Tanzania.

Table 2 shows the prevalence at the beginning of 2003 and detection during 2002 for the six top endemic countries, according to the latest avail-able information. Together, these countries repre-sent 85% of registered cases and 88% of the new cases detected in 2002.

The latest available information shows that 620,672 new cases were detected during 2002, a 18.7% decrease compared with 2001 when 763,287 new cases were detected, as indicated in Table 3

Table 4: Detection of leprosy by WHO region between 1994 and 2002, excluding Europe

Region Detection of leprosy, by WHO Region from 1994 to 2002

1994 1995 1996 1997 1998 1999 2000 2001 2002

Africa 47 900 46 516 46 489 56 507 51 530 55 635 54 602 39 612 48 248

Americas 36 623 36 842 43 783 43 159 47 218 45 599 44 786 42 830 39 939

Eastern Mediterranean 6 504 5 231 5 761 6 306 5 923 5 757 5 565 4 758 4 665

South East Asia 456 882 428 652 457 921 565 416 689 069 621 620 606 703 668 658 520 632

WesternPacific 12 737 12 135 12 613 13 573 10 617 9 501 7 563 7 404 7 154

Total: 560 646 529 376 566 657 684 961 804 357 738 112 719 219 763 262 620 638


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on the previous page. Table 4, also on the previous page, shows the detection trend by WHO Region, from 1994 to 2002, excluding Europe. The number of cases detected during 1994 was 560 646, which increased to form a peak in 1998 at 804 357, and has been declining since then. As the global target of leprosy elimination as a public health problem was reached at the end of 2000, the focus of the

New Case Detection Rates(per 100 000 population)

20 to 89.310 to 205 to 101 to 50 to 1 or no data

Leprosy: new case detection rates, 2002

Prevalence Rates at end of 2002(per 10 000 population)

3 to 7.31 to 30 to 1No data

Leprosy: registered prevalence rates, end 2002

elimination strategy has now shifted from the global level to the national level.

Data presented in this report are based on the prevailing situation at the beginning of 2003 and the annual detection in the year up to that date. In India, the annual leprosy situation is reported on the period April to March of each year, rather


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than January to December. During 2003, evalu-ation exercises were undertaken which included the updating of registers in endemic countries in Africa, and in India, Myanmar and Brazil.

In India, a national LEM exercise and a vali-dation exercise for newly diagnosed cases were completed by the end of the year (see details in Annex 1). Preliminary results indicate that a sig-nificant number of new cases are wrongly diag-nosed, previously treated cases are re-registered, or cases are simply non-existent. This is the first time that a systematic validation of new cases has been undertaken in India on such a large scale. The methodology and the process of this validation are essential for an accurate analysis of detection trends.

Though leprosy remains a public health prob-lem in 10 countries, the greater part of the global burden is now focused on the top 6 endemic countries, namely: India, Brazil, Madagascar, Mozambique, Nepal and Tanzania. The total number of cases registered in these six coun-

Table 5: Leprosy Situation in the Africa Region (AFRO) at the end of 2002 (latest available figures)Country Point

PrevalenceCases detected during the year 2002

Prevalence rate per 10 000

Detection rate per 100 000

Algeria 0 0 - -

Angola 5,249 4,272 3.9 32.1

Benin 294 392 0.5 6.3

Botswana

Burkina Faso

Burundi

Cameroon 893 1,597 0.6 10.3

Cape Verde 12 4 0.3 0.9

Central African Republic 750 388 2.0 10.5

Chad 547 233 0.7 3.0

Comoros 288 288 4.0 40.4

Congo 384 362 1.3 12.0

Cote d’Ivoire 1,552 1,358 1.0 9.0

D.R. Congo 4,859 5,037 0.9 9.5

Equatorial Guinea - -

Eritrea 27 27 0.1 0.7

Ethiopia

Gabon 44 17 0.4 1.4

Gambia 96 72 0.7 5.4

Ghana 886 204 0.4 1.0

Guinea 902 1,234 1.2 16.3

Guinea Bissau 101 68 0.8 5.5

Kenya

Lesotho 20 20 0.1 0.9

Liberia 685 560 2.1 16.8

Madagascar 6,602 5,482 4.0 33.4

Malawi

Mali 531 609 0.5 5.3

Mauritania

Mauritius 2 2 0.0 0.2

Mayotte

Mozambique 7,136 5,830 3.6 29.1

Namibia

Niger 1,026 1,207 0.9 10.9

Nigeria 5,890 5,078 0.5 4.5

Reunion

Rwanda 14 8 0.0 0.1

Sao Tome

Senegal 450 434 0.5 4.5

Seychelles 0 0 - -

Sierra Leone 449 751 0.9 15.1

South Africa 13 52 - 0.9

Swaziland 4 1 0.0 0.1

Tanzania 7,063 6,497 2.1 19.0

Togo

Uganda 714 668 0.3 3

Zambia

Zimbabwe

Table 6: Leprosy Situation in the Americas (AMRO) at the end of 2002 (latest available figures)Country Point




Anguilla 0 0 - -

Antigua 0 0 - -

Argentina 1,182 386 0.3 1.0

Barbados 0 0 - -

Belize 0 0 - -

Bolivia

Brazil 71,139 38,365 4.1 22.3

Chile 2 1 0.0 0.0

Colombia 1,728 596 0.4 1.4

Costa Rica

Cuba

Dominican Republic 283 205 0.3 2.4

Ecuador

El Salvador

Grenada 0 1 - 1.1

Guatemala

Guyana 74 38 0.9 4.4

Haiti

Honduras 8 2 0.0 0.0

Jamaica 11 2 0.0 0.1

Mexico 1,191 309 0.1 0.3

Trinidad & Tobago 68 34 0.5 2.6

Uruguay

Venezuela


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Table 7: Leprosy Situation in the Eastern Mediterranean Region (EMRO) at the end of 2002 (latest available figures)Country Point




Afghanistan 222 19 0.1 0.1

Bahrain 36 6 0.6 1.0

Djibouti 27 2 0.4 0.3

Egypt 2,405 1,318 0.3 1.9

Iran 326 82 0.0 0.1

Iraq

Jordan 0 0 - -

Kuwait 0 12 - 0.6

Libya 8 7 0.0 0.1

Morocco 340 60 0.1 0.2

Oman 6 8 0.0 0.3

Pakistan 1,983 1,202 0.1 0.7

Qatar 7 7 0.1 1.1

Saudi Arabia 28 39 0.0 0.2

Somalia 447 151 0.4 1.4

Sudan 1,639 1,361 0.5 4.5

Syria 3 3 0.0 0.0

Yemen 422 388 0.2 2.1

Table 9: Leprosy Situation in the Western Pacific Region (WPRO) at the end of 2002 (latest available figures)Country Point




American Samoa 6 0 0.8 -

Cambodia 588 740 0.5 6.5

China 3,623 1,646 0 0.1

Federated States of Micronesia

79 108 6.5 89.3

Fiji 2 4 0 0.5

Hong Kong 39 6 0.1 0.1

Korea 543 22 0.1 0

Lao People’s Dem. Rep.

162 155 0.3 2.8

Malaysia 955 181 0.4 0.8

Marshall Islands 48 52 7.3 78.8

New Zealand 3 - 0.1

Papua New Guinea

620 552 1.3 11.2

Philippines 3,334 2,479 0.4 3.2

Samoa 8 12 0.4 6.6

Singapore 25 4 0.1 0.1

Solomon Islands 26 26 0.6 5.7

Tonga 0 0 - -

Vanuatu 8 6 0.4 3.1

Vietnam 1,269 1,158 0.2 1.4Table 8: Leprosy Situation in the South East Asian Region (SEARO) at the end of 2002 (latest available figures)Country Point




Bangladesh 8,143 9,844 0.6 7.5

Bhutan 33 13 0.2 0.6

Timor Leste 249 281 2.8 31.3

India 344,377 473,658 3.2 44.4

Indonesia 16,837 12,377 0.8 5.8

Maldives 19 29 0.6 9.9

Myanmar 5,494 7,386 1.1 16.0

Nepal 7,980 13,830 3.3 56.5

Sri Lanka 1,639 2,214 0.9 11.6

Thailand 1,905 1,000 0.3 1.6

WHO, in conjunction with the national pro-grammes, has undertaken a country-by-country reassessment of the prevailing situation in the major endemic countries. This section of the report provides short profiles of some of the major endemic countries

BrazilOverview of the programme

Brazil has a well developed though complex health care system, which reflects the roles and responsibilities of different political levels - the national, the 27 federal units (or states), and 5,560 municipalities. The federal government finances about 70 percent of the public health services, the balance coming from the states and municipalities. There is also considerable inequity in access to medical services, favouring cities and the more populated Southeast.

The leprosy elimination programme forms part of the dermatology services and was designed as a semi-vertical system with leprosy coordinators in individual states. In 1998 less than 25% of local health facilities were in a position to diagnose and

tries combined represents 83% of the global prevalence and the prevalence rate is 3.4 per 10 000. India alone represents around 64% of prevalence and 76% of new cases world-wide. At the state level in India, there are eleven endemic states (having a prevalence of more than 10 000 and also a prevalence rate higher than 2 per 10 000), which together represent more than 90% of the disease burden in India. These states are: Andhra Pradesh, Bihar, Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh and West Bengal.

Major endemic countries


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Brazil

Development Indicators 1997 2000 2001

Population, total (millions) 163.8 170.1 172.4

Population growth (annual %) 1.3 1.3 1.2

National poverty rate (% of population) .. .. ..

Life expectancy at birth (years) 67.4 68.1 68.3

Fertility rate (births per woman) 2.3 2.2 2.2

Infant mortality rate (per 1,000 live births) 37.4 32 31

Under 5 mortality rate (per 1,000 children) .. 38 36

Child malnutrition, weight for age (% < 5 yrs) .. .. ..

Child immunization, measles (% < 1 year) 99 99 99

Access to affordable essential drugs %* .. 0-49 ..

Human Development Index (HDI) value * .. .. 0.777

Illiteracy total (% age 15 and above) 14.4 13.1 12.7

Illiteracy female (% of age 15 and above) 14.7 13.2 12.8

GNI per capita, Atlas method (current US$)* 4,740 3,630 3,070

GDP growth (annual %)* 3.3 4.4 1.5

Aid per capita (current US$)* 1.8 1.9 2

Source: World Bank, World Development Indicators database, April 2003 and UNDP , Human Development Report 2003.*SeeGlossaryfordefinitionofterms

Leprosy Situation MB PB Total

Cases detected during 2002** 16,569 15,583 38,390

Child cases (<15 years) amongst new cases 2,545

Grade 2 disability amongst new cases 1,601

Cases registered for treatment at end of year 78,403

Source: Ministry of Health, 2003** Individual MB and PB data incomplete for some states

Leprosy elimination in Brazil

Key indicators

• Second most endemic country in the world

• Prevalence and prevalence rate: 78,403 (4.2 / 10 000 population)

• New cases and detection rate: 38,390 (22.3 / 100 000 population)

• Geographic focus: impoverished states of North /Northeast

Highlights of activities 2003• National campaign (BBC, PAHO/WHO,

Health Ministry, MORHAN) to encour-age early help seeking behavior

• Improved awareness of the signs of leprosy

Constraints to eliminating leprosy • Limited access to leprosy diagnosis and

treatment in endemic areas• Non adherence to fixed duration treat-

ment• Very centralized programme

Remedial actions needed• Accelerate decentralization of leprosy

services in the endemic areas• Urgent need to increase geographical

coverage of MDT • S i mp l i f y i n f o r mat i o n s y s t em

(SINAN)

treat leprosy. This was clearly a major obstacle to the elimination of leprosy. In November 1998 the National Council of Municipal Health Secretaries (CONASEMS) adopted a resolution to provide leprosy diagnosis and treatment at every health facility. The framework for this new partnership was provided by a tripartite agreement between the Min-istry of Health, CONASEMS, and the Pan-American Health Organization (PAHO)/WHO.

A task force representing all key players (the National Leprosy Programme of the Minis-try of Health, the municipal health secretaries (CONASEMS), PAHO/WHO, MORHAN (a social mobilization organization for leprosy) and leprosy experts) was created in January 1999 to guide the decentralization process. The Task Force also oversaw the production and distribution of informa-tion and training kits for use in the municipalities, funded jointly by the Ministry of Health, WHO and the Novartis Foundation. Efforts focused on the priority municipalities in the states of Bahia, Piaui, Tocantins, Pernambuco, and Rio de Janeiro. Sig-nificant progress was made to that end. A major

step was the inclusion of leprosy as part of the basic health package for primary health facilities with an administrative resolution passed in 2001.

However, the momentum of the task force has been lost, as responsibility for tuberculosis has been added to the mandate of the task force and the team was expanded.

Brazil has the second highest number of regis-tered patients in the world after India. Prevalence rates at the national level are over four times the world elimination target. There has been a steady increase in new cases over the past twenty years and since 1998, over 38 000 new cases have been


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detected every year. However, leprosy elimina-tion campaigns have not contributed significantly in detecting “hidden” cases.

Prevalence rates vary considerably within the country. About 56% of registered cases come from the North and North eastern regions, as do 40% of new cases. These states have limited public health resources, especially in comparison with the richer states in the south. One-third of all hospitals are in the Southeast, and there are more than twice as many people per doctor in the impoverished Northeast state of Piauí as there are in São Paulo. Many health facilities in the high endemic states of the North and Northeast still do not provide leprosy services.

Key constraintsThe Brazilian leprosy programme is still man-

aged as a highly specialised programme with limited emphasis on integration within the general health services. There are indications from LEM exercises that patients are kept on the treatment registers long after completion of the standard course of MDT. This explains the high prevalence/detection ratio showing that the reported prevalence is sig-nificantly inflated. At the same time, however, a general process of political decentralisation is still ongoing in the country which will devolve control of public health services (including their funding) to the municipalities, and this offers some scope to increase geographical coverage with MDT.

Remedial action needed If Brazil is to meet the elimination target, special

action is urgently required to tackle the high level of transmission (especially in the North and North-east regions), to increase the geographic coverage with MDT and to make the programme more public health orientated. The large majority of new cases occur in underserved populations with little access to information and health care. As a result many remain undetected, or are detected too late.

The basic groundwork is in place, and leprosy is now part of the primary health care package. The challenge now is to work with local health services and empower them to provide leprosy services. The task force should be reactivated to continue the work initiated in the past. There is also a need to stress the importance of adherence to standard guidelines for treatment duration and updating of registers.

Leprosy awareness campaign 2003WHO commissioned the BBC World Service

Trust to conduct a national radio and television leprosy awareness campaign in Brazil in 2003, in partnership with the Brazilian Ministry of Health,

MORHAN, Pastoral da Crianca and Brazil’s major broadcasters. The month-long campaign consisted of three TV spots and ten radio spots. It ran from 29 January until 27 February 2003. Globo, SBT, Bandeirantes and Rede TV), in addition to ten other national television partners, reported the broadcast-ing of the campaign TV spots more than 7,000 times nationally. In addition, over 2,800 radio stations across Brazil were given the campaign spots.

The purpose of the campaign was to raise awareness about leprosy (called hanseniase in Brazil), its symptoms and treatment. The campaign emphasised three key messages

• How to recognize leprosy signs.• Leprosy can be treated and cured.• A person on treatment is not contagious,

and can continue to have a normal life while being treated.

Closing voiceovers added:

• Treatment is free at a Public Health Centre.

• Call Telehansen for more information, with the Telehansen number.

The campaign had broad penetration across the five regions surveyed, reaching 64% of the adults surveyed.The estimated national reach of the campaign was 73.6 – 84.7 million people. The campaign successfully communicated its mes-saging brief. Nearly three-quarters (74%) of those exposed to the campaign recalled at least one of the campaign’s main messages.

The campaign had a significant and positive impact upon the awareness of leprosy and its symptoms. Levels of hanseniase awareness and knowledge of specific symptoms are approximately 30% higher among those exposed to the campaign, compared to those not exposed. The campaign also had a positive effect on perceptions about leprosy treatment.

Correct beliefs regarding leprosy treatment and tolerance for people being treated are at approxi-mately 30% higher levels among those exposed to the campaign, compared to those not exposed.

IndiaOverview of the programme

Since the 1950s India has accorded a high pri-ority to the control of infectious diseases through a series of centrally administered disease control pro-


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India


Population, total (millions) 965.4 1,000 1,000


National poverty rate (% of population) .. 28.6 ..

Life expectancy at birth (years) 62.2 62.8 63

Fertility rate (births per woman) 3.3 3.1 3

Infant mortality rate (per 1,000 live births) 71 68 67




Access to affordable essential drugs %* .. .. 0-49


Illiteracy total (% age 15 and above) 45.1 42.8 42


GNI per capita, Atlas method (current US$)* 420 450 460

GDP growth (annual %)* 4.4 4 5.4

Aid per capita (current US$)* 1.7 1.5 1.7



Cases detected during 2002 140,936 250,839 391,775

Child cases (<15 years) amongst new cases 57,943

Grade 2 disability amongst new cases 8,353


Source: Ministry of Health, 2003

grammes, which included leprosy. In general, the performance of these centrally managed schemes has been uneven with important limitations at both the central and state levels.

There are eleven endemic states which, taken together, represent more than 90% of the disease burden in India, and have a prevalence rate of 4.6 per 10 000. They are Andhra Pradesh, Bihar, Chhat-tisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh and West Bengal. These eleven states also repre-sent a significant proportion of the registered cases and newly detected cases globally and highlight the importance of effective implementation of intensi-fied elimination strategies there.

Prevalence and detection trendsThe latest available information indicates that

there were 344 377 cases registered for treatment (prevalence rate 3.2 per 10 000), of which 473 658 new cases were detected during 2002 (detection rate 46 per 100 000). Among the new cases, the proportion of MB cases was 35% (167 095 cases); the proportion of children under 15 years old was

15% (70 463 cases); the proportion of female was 34% (160 946 cases); and the proportion of cases with grade 2 disabilities was 1.8% (8 526 cases).

The proportion of child cases remains high. This can be ascribed to one or more of the following fac-tors: continued high transmission, intense elimina-tion activities targeted to this age group like school surveys, or the factor of “over-diagnosis”. The low proportion of females could indicate a bias in detec-tion. The proportion of grade 2 disability cases is low in India compared to other countries.

The proportion of Grade-2 disability is slightly reduced to 1.8% (2.1% in the previous year), and the child proportion has declined from 16.3% to 14.9% over the same period. The female proportion of new cases however is still low, at 34%.

A structural issue, specific to the national pro-gramme in India, has been the use of new case detection targets. This practice dates back to the early days of the vertical programme and was intended as a way of ensuring wider geographical coverage of treatment and improving worker effi-ciency. At best, this has been a crude management tool when used as the sole parameter to assess the performance of leprosy workers. At worst, detec-tion targets have grossly inflated the real extent of the leprosy problem, encouraged unnecessarily high demands for MDT and - most worrying of all - even cast doubts on the feasibility of the elimina-tion strategy itself.

There is some evidence to suggest that the recent shift away from targets is already starting to bear fruit in India, and this is reflected by the 23% fall in new case detection in the twelve months up to March 2003, This period includes a fourth round of leprosy elimination campaigns, when new case detection would normally be expected to rise when compared with non-campaign years.

The new data represents a significant fall in detection even at the global level, as India rep-resents close to 76% of the global burden of the disease. Targets for new case detection have no relevance once diagnosis and treatment are fully integrated into the primary health care system, and the decision by the Indian programme not to set new case detection targets at the national level for the year 2003 is highly significant.

Although any such short term analysis of detec-tion trends is fraught with potential problems, these encouraging results may indicate that the backlog of cases within the community is finally being cleared up, more realistic estimates are now being made, and new case detection rates will now continue to fall.


13

Table 10: India: Leprosy Situation 2002-2003State or Union

TerritoryRegistered prevalence at end of

March 2002

New cases detection April 2002 - March 2003 Detection rate per 100 000

population

Registered prevalence at end of

March 2003


populationNew MB

casesNew PB cases

Total new cases

MB % Female %

Child %

Grade 2 disability %

Andhra Pradesh 24,947 7,823 29,435 37,258 21.00 39.40 25.71 1.13 47.95 19,667 2.53

Arunachal Pradesh 136 87 39 126 69.05 14.29 2.38 1.59 11.03 103 0.90

Assam 2,283 981 589 1,570 62.48 23.25 7.32 5.61 5.69 1,531 0.56

Bihar 93,709 30,267 64,294 94,561 32.01 40.08 16.11 1.48 108.60 74,871 8.60

Chattisgarh 22,930 7,529 10,939 18,468 40.77 34.76 11.28 2.65 85.93 15,482 7.20

Goa 324 121 173 294 41.16 30.27 20.75 1.36 21.28 428 3.10

Gujarat 7,309 4,078 7,486 11,564 35.26 44.85 15.43 1.28 21.95 7,392 1.40

Haryana 646 453 265 718 63.09 20.33 2.37 4.46 3.24 550 0.25

Himachal Pradesh 234 228 52 280 81.43 27.50 2.14 6.79 4.46 256 0.41

Jharkhand 35,587 10,902 18,080 28,982 37.62 35.31 16.42 1.83 103.34 18,207 6.49

Jammu & Kashmir 702 356 216 572 62.24 22.90 7.52 4.55 5.40 633 0.60

Karnataka 12,843 4,656 8,415 13,071 35.62 41.44 21.28 1.01 24.02 10,353 1.90

Kerala 2,297 1,097 1,433 2,530 43.36 41.62 16.13 3.20 7.81 2,185 0.67

Madhya Pradesh 13,834 7,300 9,270 16,570 44.06 33.38 7.70 3.77 26.28 12,027 1.91

Maharashtra 32,318 13,740 34,809 48,549 28.30 44.31 19.79 1.53 48.19 29,680 2.95

Manipur 142 47 61 108 43.52 34.26 9.26 3.70 4.29 92 0.37

Meghalaya 70 50 28 78 64.10 35.90 7.69 12.82 3.21 86 0.35

Mizoram 33 4 19 23 17.39 47.83 0.00 0.00 2.45 9 0.10

Nagaland 60 33 25 58 56.90 17.24 0.00 5.17 2.65 41 0.19

Orissa 33,329 12,067 26,282 38,349 31.47 0.00 15.99 1.72 101.45 27,660 7.32

Punjab 1,300 809 547 1,356 59.66 20.50 3.54 5.97 5.39 1,192 0.47

Rajasthan 4,284 1,291 649 1,940 66.55 32.16 3.56 3.25 3.27 4,325 0.73

Sikkim 66 18 22 40 45.00 7.50 5.00 2.50 7.00 41 0.72

Tamil Nadu 22,255 5,906 18,861 24,767 23.85 38.50 17.84 1.18 39.04 14,813 2.34

Tripura 175 35 45 80 43.75 28.75 2.50 12.50 2.44 103 0.31

Uttar Pradesh 85,631 39,952 50,634 90,586 44.10 34.02 8.33 1.51 52.13 71,647 4.12

Uttaranchal 1,912 788 1,458 2,246 35.08 29.88 8.37 2.00 25.58 1,655 1.88

West Bengal* 32,871 13,131 18,887 32,018 41.01 25.87 12.89 2.44 38.63 22,432 2.71

A & N Islands 87 23 37 60 38.33 25.00 15.00 3.33 16.06 48 1.29

Chandigarh 343 239 84 323 73.99 23.53 6.81 12.38 33.54 239 2.48

D & N Haveli 254 102 166 268 38.06 45.15 13.06 0.00 111.01 122 5.05

Daman & Diu 28 8 10 18 44.44 5.56 5.56 0.00 10.44 7 0.41

Delhi 5,921 2,916 3,059 5,975 48.80 25.87 4.05 7.13 40.23 6,339 4.27

Lakshadweep 28 4 23 27 14.81 37.04 22.22 0.00 43.17 29 4.64

Pondicherry 265 54 171 225 24.00 44.89 13.33 0.89 22.26 132 1.31

Total 439,153 167,095 306,563 473,658 35.28 33.98 14.91 1.80 44.37 344,377 3.23

*For 5 districts of West Bengal information pertains to February 2003.

Leprosy Elimination Monitoring

The TAG Sub-group on Monitoring and Evalu-ation, held in New Delhi, India, in early February 2001, recommended that LEM should be conducted on an annual basis for Group 1 countries, and on a selected basis for Group 2 and 3 countries. It was also recommended that LEM be conducted at the State level in India and Brazil, in consideration of their geographical and population sizes.

For the first LEM exercises conducted in June 2002, the National Institute for Health & Family Wel-fare (NIHFW) based in New Delhi, was identified by the Government of India as the implementing

agency. From the preparation to the implementation phase, it included all the major partners, Govern-ment of India, WHO, DANLEP, DFIT, NLR and TLM. The survey covered the 11 priority states and two additional States (Delhi and Uttaranchal Pradesh). A sample of 77 districts was drawn up, in which a sample of urban and rural health facilities was selected. This first large scale LEM served as base-line data for similar exercises to be carried out in the coming three years, and monitor the progress being achieved towards elimination. The second round of LEM was completed in August 2003. In addition, for the first time, the programme undertook a sys-tematic exercise to validate new case detection. A summary of the reports is attached as Annex 1.


14

MDT supply management in IndiaIndia absorbs about 70% of the total MDT pro-

cured by WHO annually and any significant over or under estimate of requirements can cause major problems. In order to facilitate the MDT distribution at the State level,

WHO ships directly to the Government Medi-cal Store Depots in Karnal (Haryana), Mumbai, Kolkata, Hyderabad and Chennai. Over recent years, observations by the NLEP/WHO State and Zonal coordinators in the high endemic states have shown that MDT drug stocks at the health facility

and/or district levels are often inappropriate, with either a shortage or an excess of stock. The reason may be partly due to the transition period of inte-gration, where MDT indent and storage are not yet integrated with the general drug supply.

By mid-2002 it was clear to WHO that India already had sufficient stocks of adult blister packs to last the rest of the year. The national programme acknowledged that it had surplus stocks of MDT and agreed to a postponement of around 30-40% of its planned shipments to 2003. The two charts below show the MDT supply to India over the

India: New Case Detection2001-2002

4,001 to 6,830 (23)3,001 to 4,000 (29)2,001 to 3,000 (63)1,001 to 2,000 (84)

501 to 1,000 (81)251 to 500 (57)

1 to 250 (212)No data or no cases (18)


15

Table 11: Epidemiological indicators, IndiaYear or

Indicator

And

hra

Prad

esh

Bih

ar

Chh

attis

garh

Jhar

khan

d

Kar

nata

ka

Mad

hya

Prad

esh

Mah

aras

htra

Oris

sa

Tam

il N

adu

Utta

r Pra

desh

Utta

ranc

hal

Prad

esh

Wes

t Ben

gal

Tota

ls

Prevalence trends in 12 priority states, 1998-2002 (rates per 10 000)19981999200020012002

5.54.7

53.73.2

11.718.918.712.910.9

7.98.78.57.7

10.8

714.614.610.912.9

2.32.42.62.72.4

9.25.45.8

32.3

4.93.33.73.13.3

23.97.6

11.27

8.9

7.15.3

54.13.5

4.14.76.14.3

5

21.82.11.72.2

4.86.95.32.7

4

3.67.38.85.45.3

New Case Detection trends in 12 priority states, 1998-2002 (rates per 10 000)1997-19981998-19991999-20002000-20012001-2002

7.38.9

88.86.4

15.136.721.616.6

14

12.918.812.110.713.7

10.92518

14.316.6

3.55.14.43.33.9

5.59.7

83.1

3

6.85.66.64.6

5

23.312.4

1812.312.9

6.97.5

10.25.35.1

428.6

6.85.26.6

12.42.72.22.9

4.99.26.84.45.7

417.611.97.37.4

Case Finding Indicators in 12 priority states in 2002% children% MB cases% of SSL PB% Grade 2

2719.8

5.31.4

15.434.4

0.12.2

12.637.1

2.73

14.239.8

12.4

24.929.5

70.8

848.5

2.65

22.728.5

5.91.6

15.730.6

6.41.7

27.418.123.4

1.4

9.343.7

11.9

7.838.3

0.22.3

13.837.7

0.92.6

22.134.5

5.52.9

Median delay in diagnosis

11.3 10.1 9.7 13 5.6 10.8 7.2 5.1 9.4 7.7 10.6 8 8.6

% females 41.5 35.2 36.4 28.5 46.8 34.8 47.3 40.2 44.5 38.6 NA 31.8 38.7

Child proportion trends in 12 priority states, 1998-20021997-19981998-19991999-20002000-20012001-2002

27.927.529.219.9

27

14.510.412.9

1615.4

15.71616

15.312.6

17.511.714.416.914.2

24.526

25.824.424.9

11.412.111.28.8

8

22.823.924.427.822.7

16.817

17.417.515.7

2731.731.624.827.4

7.81.78.4

10.79.3

4.64.75.2

11.87.8

1711.812.812.313.8

19.623.923.128.222.1

MB proportion among new cases trends in 12 priority states, 1998-20021997-19981998-19991999-20002000-20012001-2002

19.617.519.618.319.8

34.336.538.437.134.4

35.132.123.9

3637.1

34.138.639.935.839.8

25.921.927.929.529.5

43.338.552.948.148.5

20.123.224.932.228.5

2525.227.129.230.6

14.716.917.1

2618.1

43.939.545.544.343.7

52.149.246.545.938.3

38.636.537.941.837.7

32.832.333.735.434.5

Disability grade-II proportion trends in 12 priority states, 1998-20021997-19981998-19991999-20002000-20012001-2002

21.61.81.41.4

4.34.53.22.22.2

4.63

3.333

5.24.83.42.32.4

1.40.8

11

0.8

75.54.75.5

5

1.31.61.62.11.6

2.12.11.91.81.7

2.52

1.41.81.4

5.31

2.92.41.9

16.94.34.32.62.3

4.74.13.33.12.6

46.23.72.52.9

Single Skin Lesion proportion trends in 12 priority states, 1998-20021997-19981998-19991999-20002000-20012001-2002

NA30.712.813.5

5.3

NA1.53.22.80.1

13.716.1

7.76.82.7

NA2.2

22.7

1

37.432.319.811.2

7

3.93.2

64.42.6

35.532.426.419.7

5.9

19.118.717.315.6

6.4

44.251.239.541.323.4

5.86.74.66.7

1

11.56

4.48.90.2

17.35.53.72.90.9

14.717.114.514.2

5.5

Female proportion trends in 12 priority states, 1998-20021997-19981998-19991999-20002000-20012001-2002

4645

45.445

41.5

42.231.141.138.935.2

43.553.636.237.436.4

31.537.4

3542.728.5

31.319.321.528.346.8

34.332.633.839.134.8

47.148.146.548.547.3

NANANANA

40.2

NA39.938.544.344.5

23.937.242.835.938.6

NANANANANA

NANANANA

31.8

NANANANANA

period 2002-2003 before and after the adjusted shipment schedules. The second adjusted chart more closely approximates to the actual “demand” for MDT drugs over the period.

WHO will continue to closely monitor the MDT

stock situation in India in order to avoid shortages, or excess stocks being held unnecessarily at the sub-national levels. It is expected that this com-ponent of the programme will be better managed in the future, with the implementation of the new simplified information and reporting system.


16

MadagascarOverview of the programme

Administratively, Madagascar is divided into 6 federal provinces, which are subdivided into 28 regions, 111 sub-regions, 1 392 communes and 13 000 villages. There are currently 2 500 primary health facilities in Madagascar giving a ratio of 1 health facility for every 5 000-7 000 inhabitants. About 60% of the regions are difficult to access, especially in the rainy season.

The leprosy elimination programme is a semi-vertical programme. The director of the leprosy/ tuberculosis programme at the central level, is sup-ported by leprosy-TB managers at the provincial level. However at the district and peripheral level, leprosy is integrated into the general health serv-ices, although many primary health workers have not been trained and are often not in a position to diagnose and treat leprosy.

The first serious effort to eliminate leprosy from

Madagascar


Population, total (millions) 14.1 15.5 16


National poverty rate (% of population) 73.3 .. ..





Child malnutrition, weight for age (% < 5 yrs) 40 .. ..


Prevalence of HIV (female, % ages 15-24) .. .. 0.2



Illiteracy total (% age 15 and above) 36 33.5 32.7



GDP growth (annual %)* 3.7 4.8 6





Child cases (<15 years) amongst new cases 823

Grade 2 disability amongst new cases 437



Madagascar was intiated in 1992 with training basic health staff and the introduction of MDT. LECs and SAPELs were conducted in order to reach the many remote and high endemic areas in the country. In 2000 the groundwork to decentralize leprosy services was started but was derailed due to the political tensions in the country. In 2003 leprosy elimination efforts have regained momentum and a national plan for the elimination of leprosy has been developed.

Since 1992 there has been a steady increase in the number of new cases with a peak in the years 1997 and 1998 as a result of the LEC and SAPEL campaigns. At the end of 2001 all the regions, except for Antananarivo had a prevalence rate higher than 4 per 10 000 inhabitants. With the updating of the registers at the end of 2002 there was a 64% drop in registered cases. In total 67 371 cases had been detected in the past decade with most cases detected in the second half of the decade.

Key constraintsLeprosy elimination efforts in Madagascar face

numerous problems including poor geographical access to many districts, particularly in the rainy seasons, fear of leprosy, lack of trainined health staff and poor management of MDT supplies, inad-equate logistical support at the district level and

Leprosy Elimination in MadagascarKey indicators (2003)

• Prevalence and prevalence rate: 6,602 ( 4.0 / 10 000 population)


• Geographic focus: entire country except capital district

Highlights of activities 2003 • Updating of registers • Development of plan to intensify lep-

rosy elimination effortsConstraints to eliminating leprosy

• Poor geographical access to many health facilities especially in rainy season

• National leprosy programme needs to be restructured

Remedial actions needed• Strengthen and restructure leprosy

programme • Make leprosy diagnosis and treatment

available at all health facilities • Social mobilization in hyperendemic

areas


17

Mozambique



Population growth (annual %) 2 2.1 2

National poverty rate (% of population) 69.4 .. ..





Child malnutrition, weight for age (% < 5 yrs) 26.1 .. ..




Illiteracy total (% age 15 and above) 59.4 56 54.8

Illiteracy female (% of age 15 and above) 74.7 71.3 70



Aid per capita (current US$)* 57 49.6 51.7








centres, and the creation of Provincial Task Forces in the five northern provinces.

Constraints to eliminating leprosy The leprosy programme remains vertical and

the health service coverage is very low particularly in the high endemic areas. The MDT distribution system is still highly centralised and inflexible, with patients having little access to treatment in their own community.

Remedial actions neededIn the WHO regional meeting in Maputo in Sep-

tember 2000, various strategies were developed including the organization of two-week leprosy information campaigns for social mobilization to promote active community participation, train-ing of staff and decentralization of activities and resources at the level of the provinces. The Maputo meeting also recommended that MDT coverage should be extended to all the health centres, or even to all the villages in the high endemic zones. The participation of community health workers in the management of leprosy cases and flexibility in the supervision of the treatment were recom-

MozambiqueOverview of the programme

The health sector in Mozambique has suffered from the prolonged civil war, low levels of financ-ing and limited technical capacity. The coverage of health service is still very low and estimated at around 42%. The infant mortality rate is one of the highest in the world. The leprosy elimination pro-gramme is a vertical service but is moving gradually towards decentralization and integration.

Leprosy is highly endemic in Mozambique with a national prevalence rate at the beginning of 2003 of 3.6 per 10 000 population. The disease is concentrated mainly in 5 provinces with prevalence rates ranging from 2.5 per 10 000 (in Manica) to 10.3 per 10 000 (Nampula). The geographic coverage of leprosy services is very poor in the endemic districts and ranges from 2% in Manica to 60% in Zambezia. This low coverage is linked with the poor coverage of health services in these provinces. The supervision of workers is inadequate and not well organized.

With WHO’s encouragement, a National Task Force was created and started functioning in the first quarter of 2000. A plan of action to accelerate leprosy elimination activities was formulated in an informal meeting held in Geneva in May 2000 with the participation of all the partners. Various solu-tions were developed including a survey to evalu-ate the geographic coverage of MDT services in the villages, conducting LECs in the provinces in the north combined with the opening of new MDT

limited knowledge of the technical guidelines. Many taboos and myths still surround leprosy which will need serious efforts in developing IEC strategies for changing the negative image of leprosy in the communities.

Remedial actions neededThere is an urgent need to make leprosy

services available at all health facilities (whether public or those run by religious organizations). This will involve training of health staff, MDT supplies, using WHO guides, coordination and supervision. In addition a special effort must be made in the hyperendemic districts to update registers and conduct social mobilization programmes to detect hidden and new cases.

This will require restructuring the leprosy elimi-nation programme at the national and provincial level to strengthen the support to the basic health centres. To train provincial teams to guide and lead the activities in the periphery and thereby help ensure the availability of leprosy diagnosis and MDT at all health facilities.


18

mended as a means of encouraging patients to report regularly for treatment. Information cam-paigns in the community should insist on the early signs of leprosy and the availability and free supply of leprosy drugs.

As a first step leprosy services will be made available in all 419 health facilities in the high endemic provinces of Nampula, Cabo Delgado, Zambezia, Niassa and Manica. This will involve the training of health staff as well as reorganizing the supervision. In addition, social mobilization efforts will be initiated in the 81 districts of these provinces to encourage people to seek diagnosis and treat-ment. Another key activity will be the updating of the leprosy registers in the three most endemic provinces.

In view of the poor coverage of health services, alternative means to improve access to MDT have been initiated in the past, including the creation of MDT distribution points as well as involvement of volunteers to suspect leprosy. The impact of these activities still needs to be assessed.

Import regulations made by the Mozambique authorities in 1996 are still in place, which continue to cause lengthy delays in WHO shipments.

Leprosy elimination in MozambiqueKey indicators (2003)



• Geographic focus: five endemic prov-inces in the North

Highlights of activities 2003 • Implementation of MDT distribution

points • COMBI (Communication for behavioral

change) to encourage people to check their skin for leprosy

Constraints to eliminating leprosy • Poor geographical access to leprosy

services due to limited coverage of health facilities

• Highly centralized programmeRemedial actions needed

• Improve patients access to leprosy services by making MDT available in all existing facilities

• Developing innovative ways to extend coverage of MDT services

• Decentralizing leprosy services • Involving volunteers in recognizing

leprosy

NepalOverview of the programme

Leprosy is considered a public health problem in Nepal owing to the magnitude of the disease burden and its hideous consequences. In the last couple of years, besides well-planned regular activities of case detection and case holding, other special activities were also carried out such as intensifying IEC activities, skin camps and launching leprosy elimination campaigns. All these activities have helped a lot to reduce the disease burden in the country.

Key constraints Poor security conditions in the field and difficult

terrain has led to a large number of defaulters.

It is urgent in Nepal to conduct an in-depth analysis to gain a clearer picture of the leprosy situation with special attention to districts faced with security problems . In addition, Regional and District health authorities should be strengthened

Nepal


Population, total (millions) 21.4 23 23.6







Child malnutrition, weight for age (% < 5 yrs) .. .. 48




Illiteracy total (% age 15 and above) 61.7 58.3 57.1

Illiteracy female (% of age 15 and above) 79.2 76 74.8












19

and more involved in the development of plans of action for leprosy elimination. Continued training of health workers, together with strengthening supervision and monitoring by management train-ing workshops for district health officers, introduc-tion of accompanied MDT services to improve cure rate, and intensified case finding activities such as focused LECs are the key strategies to intensify leprosy elimination activities.

Remedial actions neededAccessibility is to be further improved by

strengthening the integration of MDT services up to the sub-health post level in all the Regions. IEC materials and simplified guidelines for elimination in local language will be provided to all health facili-ties to improve the MDT services and community awareness. In addition, mass media will be used to promote community awareness and to reduce the stigma against those who have contracted the disease.

TanzaniaOverview of the programme

The Tanzania National Tuberculosis and Lep-rosy Programme (NTLP) was launched by the Ministry of Health in July 1977. The Programme is funded by the Tanzanian government and external donors from both governmental and non-govern-mental organisations. There is structural and func-

Tanzania










Child immunization, measles (% of < 1 year) 73 78 83



Illiteracy total (% age 15 and above) 28.5 25 24






Leprosy Situation 2002 MB PB Total






tional integration of leprosy control services into the general health care services and a dedicated and well financed National Central Coordinating Unit. The NTLP is integrated in the existing pri-mary health care system, with all health providers responsible for early case detection, appropriate treatment and case holding. The managerial and supervisory staff at the national, regional and district level ensure adequate technical competence of all health workers involved.

The MDT distribution system apparently works well throughout the country, from the National Central stores, to the Regional Drug stores, and onward to the Districts and Health facilities. National strategic plans for leprosy elimination are drawn up on an annual basis.

Tanzania achieved full coverage of registered leprosy patients with WHO recommended MDT very late as the programme used Isoprodian based regi-mens, supplied by GLRA until 1997.

The registered leprosy prevalence in Tanzania has been declining over the years from 26,630

Leprosy elimination in NepalKey indicators (2003)



• Geographic concentration: entire coun-try except capital district

Highlights of activities 2002 • Updating of registers • Development of plan to intensify lep-


• Poor geographical access to many health facilities especially in rainy season and due to security problems

• National leprosy programme needs to be restructured depending on the security situation.

Remedial actions needed• Strengthen and restructure leprosy

programme • Make leprosy diagnosis and treatment

available at all health facilities


20

Leprosy elimination in TanzaniaKey indicators (2003)



• Geographic focus: 13 out of 21 regions

Highlights of activities 2002 • LEM highlighted problems and updating

of registers • Development of plan to intensify lep-


• Out-of-date guidelines, procedures and registers

• Poor geographical access to many health facilities

Remedial actions needed• Update guidelines, procedures and

registers• Conduct LECs and SAPELs in high

endemic areas• Make leprosy diagnosis and treatment

available at all health facilities • Community awareness of leprosy

cally difficult to access areas, refugee populations and nomadic populations.

Key constraintsDespite substantial NGO involvement over

many years, a LEM study in 2002 found many weaknesses in the national programme. The reporting and recording formats were outdated and treatment registers were not up-to-date.

The guidelines were printed in 1995 and need to be updated to include recent internationally accepted leprosy control policy changes such as the duration of treatment for MB patients. MB patients are still treated for 24 months, in spite of the fact that the NTLP had accepted the policy of 12 MB doses recommended by the WHO Expert Committee in 1997. The guidelines also combined the old method of classifying of leprosy patients (TT, BT, BL LL) instead of the WHO standard classifica-tion of PB and MB.

MDT drugs are supplied by WHO according to the various registered categories of leprosy patients, i.e, MBA, MBC, PBA, and PBC. In the NTLP reporting formats in Tanzania, the LEM found that there were no columns for indicating the leprosy data according to the WHO classification, which made it practically impossible to order the correct quantities of MDT blister packs.

Other weaknesses include low community awareness on leprosy, low MDT coverage in some areas due to displaced populations and difficult to access areas, and an over-treatment of leprosy patients with MDT drugs.

Remedial actions requiredThere is a need to “clean” (update) the treat-

ment registers. While new cases, relapses, and patients resuming treatment have continued to be added to the registers and considered to reflect the existing prevalence for that particular period, those patients having completed treatment, who had died or been transferred to other areas, or had defaulted were never removed from the reg-isters. The registered caseload therefore was grossly inflated. This has in turn led to a much higher demand for MDT drugs than necessary, and possible wastage due to drugs expiring before they are used.

Key actions which need to be undertaken urgently include updating guidelines and regis-ters, conducting LEC and SAPEL in high endemic areas, promoting community awareness on leprosy disease, expanding the coverage of MDT services and building the capacity of local health workers to diagnose and treat leprosy.

in 1985 (prevalence rate 11.8/10,000) to about 7,000 in 2003 (prevalence rate 2/10,000). Despite the decline in the number of leprosy cases, the proportion of new patients with disabilities has not changed significantly over the years (15% disabil-ity grade 2, falling to 11% after starting LECs).

This indicates that there is a delay in the diag-nosis of leprosy in the National Programme and by implication, many hidden cases. Moreover, leprosy case detection has remained stable over the years (between 3 000 and 4 000 cases per year).

Leprosy Elimination Campaigns and SAPELs have been carried out from 1998 to 2002 leading to an increase in the annual case load from 3,963 reaching 7,000 cases during 2002. The proportion of children among the newly diagnosed leprosy patients is still high (11%) in 2002. The MB pro-portion of the registered leprosy patients is 58%, indicating a high source of leprosy infection.

The ratio between registered prevalence and case detection rate is 1.12, denoting that patients take longer time than the recommended to com-plete MDT. By the beginning of 2003, 13 regions out of 21 in the country had a leprosy prevalence rate above 1/10 000 population. In addition, some regions have special situations such as geographi-


21

Trends in MDT drug supplySince 1995, WHO has supplied MDT free of cost

to over 80 different countries and territories, using funds initially donated by the Nippon Foundation (during the period 1995 to 1999) and thereafter using a donation in kind from Novartis. The current donation runs until the end of 2005 but an exten-sion is under review by Novartis. WHO is confident that it will be able to continue a free supply of MDT drugs to all its Member States for the foreseeable future.

The first of the two charts below gives an indica-tion of how the supply of MDT drugs (both quantities and blister type) has changed over the period 1995 to 2003. Quantities of drugs shipped should not be interpreted as accurately reflecting either the global prevalence or the new case detection during individual years, for a number of reasons.

The main reason is that few national pro-grammes are able to supply WHO with accurate stock figures at the regional or district levels. As a consequence there is a tendency on the part of programmes to over-estimate their requirements which are only corrected during the following year’s supply cycle, when it becomes clear to programme managers that regions and districts are not “draw-ing down” fresh supplies from the central level as fast as expected.

Such annual cyclical “re-adjustment” is only feasible if the MDT supplied has a long shelf life, otherwise losses due to expired drugs would be unacceptably high. Fortunately, careful planning

each year by WHO and Novartis ensures that the MDT supplied has a long shelf life of between 3 to 4 years, and WHO is able to compensate an oversupply to individual countries in one year by a corresponding under supply the following year.

The quantities shown over the period 1995-2001 in the first chart are actual amounts procured and shipped to countries. However, the year 2002 saw an important departure from this established cyclical supply when India acknowledged it was overstocked and agreed that some 30-40% of its shipments scheduled for delivery that year could be postponed until the first half of 2003.

To illustrate the significance of this postpone-ment, the second of the two charts shows actual shipments (rather than procurement) during the period 2002-2003. The planned supply in 2002 was initially larger than in 2001 but due to the post-ponement of the Indian shipments this has been reversed. The second chart therefore, despite the many limitations outlined above, provides a more realistic reflection of long term trends in MDT con-sumption than the first chart.

MDT procurement and supplyAnnual meetings are held with Novartis (usu-

ally in November) to finalise the projected require-ments for the following year’s supply of MDT. Such

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

1995 1996 1997 1998 1999 2000 2001 2002 2003

WHO MDT Supply: 1995-2003

MB Adult MB Child PB Adult PB Child

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

1995 1996 1997 1998 1999 2000 2001 2002 2003*

WHO MDT Supply (Adjusted): 1995-2003

MB Adult MB Child PB Adult PB Child* Adjusted to show postponement of 30% of 2002 India shipments to 2003.

MDT Drug Supply by WHO

• Planning annual production and supply of MDT with Novartis and procuring on behalf of all endemic countries;

• Collecting, compiling and checking annual country requests;

• Using experienced and reliable freight forwarders to reduce possible shipment delays, providing emergency supplies, and establish planned supply cycles to match requirements and avoid overstock-ing;

• Assisting in customs clearance of ship-ments at the country level through the WHORepresentatives’office;

• Standardising the reporting of registered prevalenceandMDTdrugflowinforma-tion systems on a sub-national, rather than national, level;

• Producing guidelines for national man-agers, and arranging meetings on drug supply systems during national and inter-national conferences;

• Developing simple computerized data-base systems to record drug flowandother essential indicators at sub-national levels.

MDT Drug Supply


22

meetings are essential as Novartis has to plan its procurement of raw substance well in advance and schedule production of rifampicin, clofazimine and dapsone with contract agents and subsidiaries.

Blistering contractors also have to plan their own procurement of the blistering materials and packag-ing from a number of suppliers so that production can continue without interruption and the drugs can be shipped with the maximum shelf-life possible.

New packaging and blister designThe year 2002 was an important one for the

MDT supply in that Novartis carried out a full-scale re-appraisal of blister design and packaging, aimed at improving resistance to environmental heat, moisture and physical damage in the field, as well as making the treatment more “patient friendly” - an important factor in treating a disease that carries with it the stigma of the past. New packs of six blisters was introduced in early 2003, with improved strength and rigidity, and corresponding to a full course of treatment for PB patients, while two packs would accommodate the full course for MB patients. These packs perfectly complement the current WHO initiative to encourage treatment within the community using “Accompanied MDT”, as patients now have an alternative choice to the monthly “supervised” doses usually insisted upon by centralised delivery systems, often at the cost of low patient compliance. The boxes are now presented in four languages and contain patients’

information leaflets in English, French, Brazilian Portuguese and Hindi. Field packs (containing 8 boxes of blisters) and transport packs have also been completely re-designed, made physically smaller for easier handling and increased strength, and patient information leaflets in several languages will be inserted to promote use of the MDT at the community level. For Novartis, this has involved substantial new investment costs.

Quality assuranceAlthough Novartis routinely takes care of qual-

ity assurance prior to the release of the individual drugs to the blistering contractor, WHO continues to conduct its own tests of every batch at independ-ent laboratories in Switzerland and at a WHO col-laboration centre in Hungary. As its blister packs are now used by practically all patients currently under treatment, WHO considers such independent testing is essential to maintain the confidence of national programmes. WHO is reimbursed for the costs incurred in conducting these batch tests by the Novartis Foundation, which also covers the cost of airfreight and insurance to the endemic countries supplied with the drugs.

Buffer stock levelsAs close to 100% of all leprosy patients in the

world now depend on WHO for their MDT supply, buffer stocks have become essential in order to avoid unexpected interruptions in production or supply. When endemic countries submit an

WHO Supply of MDT 1995-2003First Supplied 2003Supplied 1995-2002No supply

Leprosy: MDT supply to countries 1995-2003


23

emergency request for MDT to WHO, any delay in meeting that request gives a clear indication that global buffer stocks are inadequate or non-existant. There is an immediate loss of confidence and thereafter a tendency to make unreasonably large requests in order to create buffer stocks at the national and even sub-national levels.

National buffer stocks - their relevance and appropriate size - are often the subject of discus-sion between national programmes and WHO, and in recent years WHO has deliberately pro-vided many of the larger programmes with more stocks than are really required, adjusting this on a year to year basis. However, too large a level of national buffer stocks can result in losses, not only because of less than optimal storage condi-tions in the countries concerned but because of common weaknesses in inventory control at all but the central level. In practically all cases it is impossible for the excess drugs to be used in other national programmes - due to import restrictions and high cost - and in some large countries even moving surpluses in one region to another facing shortages can be problematic. As a result the drugs can expire before use.

A more viable alternative is a substantial global buffer stock of MDT kept under optimum storage conditions, constantly rotated and made immedi-ately available by air freight as required, following the well established “First in, first out” principles of drug supply management. The optimal size of the global buffer stock is reviewed each year and in 2004 is planned to be at a level of over 1 million blisters.

Use of the Geneva buffer stockFrom 1995, WHO has also maintained a small

buffer stock of MDT in its Geneva headquarters, primarily in order to meet small emergency requests but also to fill “gaps” in the regular annual supply to small programmes. Smaller but similar buffer stocks are maintained at the regional office of WHO for the Western Pacific (WPRO) in Manila and also at the WHO office in Fiji, which covers several small isolated islands in the South Pacific. Using small buffer stocks is a faster and more cost effective way of supplying small quantities of the MDT to these remote Pacific islands.

In the case of emergency shipments made from the Geneva buffer, the reponse time (from receipt of the request until the despatch of the MDT) can be as little as 24 hours, and in most cases the drugs are sent by courier, with shipments trackable on the courier’s website. Details of the use of the Geneva buffer stock during 2003 is provided in Annex 2 of this report.

Supply of loose clofazimine

From early 2003, WHO has administered the distribution of a Novartis donation of loose clofaz-imine (Lamprene) to treat severe ENL reactions in leprosy. Following the same distribution system as used with the MDT blisters, clofazimine has been made available to any endemic country on official request to WHO from the Ministry of Health.

Part of the donation was earmarked for IDA Netherlands as they had accumulated many commercial requests for the drug from endemic countries prior to the donation. However, IDA and the German NGO Action Medeor have agreed to pass on to WHO any future requests for the drug from countries so an assessment can be made as to whether the requests of Lamprene are for use in leprosy or for “off label” use, which would not be acceptable under the terms of the donation.

Many requests for Lamprene made during 2003 to WHO have been unrealistically large, particularly from those NGOs ostensibly acting on behalf of national programmes. WHO policy has been to refer such requests back to the Ministry of Health in the country concerned and in all cases this has resulted in a lower, more realistic MoH request being submitted. WHO has produced guidelines for the management of severe ENL reactions in leprosy which are sent to all countries making a request for loose Lamprene. The guidelines include a calculation of the Lamprene required in treating the reaction, either in combination with prednisolone or by itself.

Uniform MDT (U-MDT)Field trials using the new Uniform MDT (U-MDT)

are being implemented in 2003, first in India and then in China. This series of field trials is designed to measure the efficacy of a shortened treatment (6 month course) for all types of leprosy, compared with the present standard 12 month regimen (MDT with clofazimine) for MB patients and 6 month regi-men (MDT without clofazimine) for PB patients.

If the uniform MB regimen is eventually adopted as the standard form of treatment for both types of leprosy this will have many implications, not only for diagnosis and patient care but for the MDT drug supply and logistics.

Special Campaigns for EliminationIn recent years, campaigns have been carried

out in areas presumed to have high caseloads of leprosy or among population groups where services

Special Campaigns


24

are inadequate. Most of the cases in the selected areas have yet to be diagnosed and treated. In these circumstances, the coverage of MDT services is typically poor, awareness about the disease is low and the negative images traditionally associ-ated with leprosy persist in the community. These factors have prevented patients from coming for-ward for diagnosis and treatment at an early stage, thus increasing the risk of their becoming disabled and transmitting the disease to others. Campaigns helped to focus attention on these areas and improve the situation as quickly as possible. They combined the following three objectives:

• capacity-building of general health workers to provide MDT services to the communities they serve;

• raising community awareness and encour-aging participation, promoting self-report-ing and removing negative perceptions about the disease; and

• ensuring that all cases of leprosy are diag-nosed and that patients receive a full course of treatment.

In addition, in many programmes there is a significant “gender gap” in accessibility to MDT services for women. Efforts were made during the campaigns to ensure that this gap is narrowed. The Special Campaign itself is usually of short duration and the activities concentrated on are as follows:

• case-finding through creating communityawareness (self-reporting by patients) and

Table 12. Detection during the Special Campaigns conducted during 2002

Area and country Population covered

Detection during Special Campaigns 2002

Total Cases

detected

Detection rates (per 100 000)

MB (%) Grade 2 disability

(%)

Child cases

(%)

Female cases

(%)Ayeyarwaddy Division, Myanmar 6,626,076 955 14.41 44.9 17.8 8.5 NA

11 Districts (130 village development committees), Nepal

887,888 430 48.42 39.3

West Bengal State, India 82,874,001 5,047 6.08 30.2 0.7 17.7 44.2

Uttar Pradesh, India 173,779,132 15,195 87.43 34.6 3.2 9.9 38.8

Uttaranchal Pradesh State, India 8,780,669 112 1.27 25.0 0.8 5.4 30.4

Madhya Pradesh State, India 63,046,606 1,406 2.23 36.8 4.3 7.3 36.6

Chhattisgarh State, India 21,492,111 3,523 16.39 35.1 1.5 13.8 42.0

Orissa State, India 37,801,485 9,457 25.01 26.9 2.4 17.1 48.9

Bihar State, India 87,074,534 32,961 37.85 26.4 2.0 16.5 44.3

Kharkand State, India 28,045,996 9,542 34.02 30.9 1.7 15.7 40.2

Challenges for Special Campaigns

The challenges commonly encountered in carrying out Special Campaigns include:

• Poor coverage – activities may cover only a small portion of the population in the target areas.

• Inadequate community awareness – information provided to the commu-nity may not be appropriate and the communication methods used may be unattractive or ineffective.

• Limited involvement of the general health services – the general health services may not be fully involved during and after the Campaigns, which will create problems in sustaining MDT services.

• Emphasis on detection – over enthusi-asm on the part of health workers and volunteers in detecting cases may result notonlyinasignificantproportionbeingwrongly diagnosed but also in the rereg-istration of previously treated cases as new cases (recycling).

• Inadequate preparation – poor planning leads to the existing health infrastructure being unable to cope with the increased demand for MDT services, which in turn results in drug shortages, and in patients getting irregular or no treatment.


25

Table 13. Detection trends during Special Campaigns in areas where it has been repeated

Area and country Detection during the Special Campaigns

First Series Second Series Third Series Fourth SeriesTotal MB% G2D% Total MB% G2D% Total MB% G2D% Total MB% G2D%

West Bengal State, India 39,275 32.9 3.8 17,167 33.4 2.7 12,653 30.4 1.7 5,047 30.2 0.8

Uttar Pradesh State and Uttaranchal State, India

57,817 36.8 3.9 41,106 43.5 3.6 31,203 38.8 1.5 15,307 34.6 3.2

Madhya Pradesh and Chhatisgarh States, India

20,248 31.8 6.1 17,176 37.7 5.1 14,970 33.6 2.6 4,929 35.6 2.3

Orissa State, India 62,844 24.4 2.5 27,197 23.6 2.2 12,326 25.5 1.5 9,457 26.9 2.4

Bihar and Jharkhand States, India 206,495 37.2 5.5 80,496 37.9 4.4 60,967 33.3 3.0 42,503 27.4 1.9

Ayeyarwady Division, Myanmar 3,162 43.3 26.1 2,547 54.5 14.7 955 44.9 17.8 - - -

Rupandehi District, Nepal 353 58.6 16.4 435 53.8 18.4 343 35.0 6.7 - - -

Notes: MB%=multibacillary proportion among the newly detected cases. G2D%=Grade 2 disabilities proportion among new detected cases.

providing clear information on where to go for diagnosis;

• startingtreatmentwiththefirstdoseofMDTand providing clear information on how to continue taking the treatment;

• providing enough treatment or information about where to go for continuation of treat-ment; and

• removing negative perceptions about the disease through intense information, edu-cation and communication (IEC) activities,

using various communication methods specially adapted to local situations.

AchievementsTable 12 on the previous page shows details of

new cases detected during Special Campaigns in 2002 in India, Myanmar and Nepal.

Table 13 above shows the number of new cases detected during each round of Special Campaigns. In India the new case detection declined consistently

Table 15. Annual detection trends in areas with repeated Special Campaigns

Area and country Annual new case detection

1995 1996 1997 1998 1999 2000 2001 2002

West Bengal State, India (1998, 1999, 2001 and 2002) 34,000 27,907 38,134 71,728 54,934 35,666 46,620 32,108

Uttar Pradesh & Uttaranchal States, India (1998, 1999, 2001 & 2002) 59,016 64,640 55,859 107,632 111,436 88,198 114,630 92,832

Madhya Pradesh and Chhatisgarh States, India (1998,1999, 2001 & 2002) 34,538 36,300 31,449 56,319 47,832 41,599 47,072 35,038

Orissa State, India (1997, 1999, 2001 & 2002) 45,865 42,252 99,341 41,534 65,329 45,216 48,144 38,349

Bihar and Jharkhand States, India(1997, 1998, 1999, 2001 & 2002) 51,265 99,599 104,478 277,336 172,449 137,172 165,682 123,523

Mandalay Division, Myanmar(1998, 1999 & 2001) 1,443 1,288 1,585 2,330 5,099 2,301 2,552 1,055

Ayeyarwady Division, Myanmar(1998, 1999 & 2002) 1,263 1,269 1,007 2,609 5,735 1,286 777 1,735

Magway Division, Myanmar(1998, 1999 & 2001) 1,438 1,358 1,201 2,814 4,463 1,569 1,426 723

17 Districts (terrai areas) Nepal(1998 & 2001) - 4,354 3,791 14,952 5,646 5,751 5,803 -


26

Table 14. India: Fourth MLECState or Union Territory New case detection by category Grade 2

disabilityNew case detection by age & sex

MB PB SSL* Adult Child

M F M F

Act

ive

Sear

ch

Bihar (P) 8,694 24,267 0 646 15,437 12,085 2,927 2,512

Chhattisgarh 1,236 2,246 41 54 1,771 1,267 271 214

Jharkhand 2,952 6,300 290 165 4,924 3,123 781 714

Uttar Pradesh 5,265 9,735 195 490 8,501 5,249 855 645

West Bengal 1,522 3,504 21 38 2,350 1,803 467 427

Madhya Pradesh

Orissa 2,547 6,910 0 229 3,978 3,861 853 765

Uttaranchal 28 78 6 1 76 32 4 2

Total for Active Search: 22,244 53,040 553 1,623 37,037 27,420 6,158 5,279

Volu

ntar

y R

epor

ting

Syst

em

Madhya Pradesh 87 597 421 43 702 351 44 32

Orissa 0 478 195 22 382 179 62 50

Uttaranchal 20 131 100 8 161 76 3 11

Andhra Pradesh 130 1,909 414 28 989 756 400 308

Arunachal Pradesh

Bihar 0 490 230 17 424 168 79 49

Goa 0 10 6 1 7 7 1 1

Gujarat 96 354 235 8 317 260 65 49

Chhattisgarh 9 633 354 19 506 288 109 93

Jharkhand 16 209 172 9 231 100 32 34

Karnataka 117 1,528 666 20 1,051 658 320 282

Lakshadweep

Maharashtra 715 4,124 1,327 48 2,573 2,288 715 590

Uttar Pradesh 72 1,344 1,057 52 1,524 692 171 86

West Bengal 22 673 473 44 612 332 115 109

Tamil Nadu

Chandigarh

Pondicherry 6 41 14 - 25 28 7 1

A & N Island

Delhi 8 78 90 8 132 34 7 3

Dadar & Nagar Haveli 17 23 2 - 13 20 5 4

Daman & Diu

Total for Voluntary Reporting System: 1,315 12,622 5,756 327 9,649 6,237 2,135 1,702

Pass

ive

Det

ectio

n

Haryana

Punjab

Himachal Pradesh

Nagaland 7 13 1 0 17 4 0 0

Sikkim

Tripura

Meghalaya 0 9 6 0 8 4 0 3

Mizoram

Assam

Jammu Div.

Kashmir Div. - 2 22 3 17 6 1 -

Kerala 0 96 74 0 73 64 19 14

Manipur

Rajasthan

Total for Passive Search: 7 120 103 3 115 78 20 17

Grand total for MLEC: 23,566 65,782 6,412 1,953 46,801 33,735 8,313 6,998

Source: Govt. of India, DGHS


27

2. MDT services include diagnosis, treatment with MDT, coun-selling for patients and their families, community education and referral for complications.

Special Action Projects

during each round of Special Campaigns, especially in the high endemic states where volunteers from the local community carried out a house-to-house search for individuals with suspicious skin lesion(s). This was also seen in Ayeyarwady Division of Myan-mar. The decline could be due to each round of Special Campaign reducing the pool of backlog (hidden) cases in these areas.

Table 14 shows details of the new case detec-tion in the various States during the fourth round of campaigns.

Table 15 shows new cases detected annually in areas where Special Campaigns were repeated. A decline in the annual new case detection was observed in Mandalay and Magway Divisions of Myanmar particularly in 2002. A similar decline was seen in West Bengal and Orrisa States in India inspite of intensive efforts to detect new cases during the past four rounds of Special Cam-paigns. However, such a decline in the annual new case detection has not been observed as yet in the remaining high endemic states of India and in Ayeyarwady Division of Myanmar.

It is important that MDT services are maintained at current level irrespective of detection trends, so that new patients are able to self-report easily for diagnosis and treatment without unnecessary delay at the nearest health centre. Furthermore, detection trends can be interpreted with some confidence only if the coverage of MDT services are maintained at current levels.

Elmination Campaigns have proved to be very useful in improving MDT services and in strengthen-ing integration. However, the area chosen for such an activity needs to be carefully selected in order for it to be cost-effective. The challenge in future will be to implement a simple and cost-effective information, education and communication (IEC) strategy within an integrated primary health care system to promote early diagnosis and encourage patients to self-report for treatment.

Special action projects for the elimination of leprosy (SAPELs) were launched in 1995 with the objective of providing multidrug therapy (MDT) serv-ices2 to patients living in difficult-to-access areas or to those belonging to neglected population groups. Difficult-to-access areas are defined as geographi-

cally remote and urban or peri-urban slums where a health care infrastructure does not exist, or where existing health care services are unable to deliver MDT services.

Particular attention was focused on neglected population groups in order to promote equity in health care. This initiative was one of several projects supported by WHO to help national pro-grammes achieve the goal of eliminating leprosy as a public health problem – defined as reduction of the leprosy prevalence at a given point in time to a level below 1 case per 10 000 population at the national level.

National programmes were encouraged to review the geographical coverage of their MDT services and to identify specific areas and popula-tions where special efforts were needed to reach and treat patients.

WHO actively supported SAPELs in endemic countries by providing technical and financial sup-port to national programmes to implement these projects. In addition, various partners working in endemic countries provided funds, logistics and human resources.

AchievementsReaching out to patients

From 1995 to 2002, national programmes, with active support from WHO and local and interna-tional nongovernmental organizations, conducted 86 SAPELs in 28 endemic countries (see Table 14). Projects were developed and implemented by national authorities, taking into consideration the prevailing local situation. Innovative and flexible approaches were used to provide MDT services to patients living in difficult-to-access areas. Mobile teams comprising specialized health care workers were deployed to these areas for varying periods of time, where awareness promotion activities (educational talks, display of banners and posters and video plays) were conducted in the villages. Individuals voluntarily reporting with suspicious skin lesions were screened and those diagnosed with the disease were registered, counselled and promptly treated with MDT.

More than 7,400 new patients were detected and treated with MDT free of charge. The propor-tion of multibacillary leprosy among newly detected cases ranged from 14% in Parbhani district (Kalam-nuri Taluka area) of India to 84% in Johongly state (Bibor area) in Sudan. In addition, more than 2,000 former patients who had been partially treated with dapsone monotherapy and had defaulted were re-treated with MDT.


28

Table 16. Regional distribution of SAPELsWHO Region Country (number of projects) Estimated

population coverage

No. of cases detected and

treated (per 100 000 population)

Africa Central African Republic (1), Chad (2), Congo (1), Côte d’Ivoire (1), Democratic Republic of the Congo (4), Madagascar (3), Mali (3), Nigeria (2), Togo (1), United Republic of Tanzania (1)

2,058,585 3,030 (147.18)

Americas Bolivia (1), Brazil (10), Colombia (1), Paraguay (1), Venezuela (2) 1,317,690 770 (58.44)

Eastern Mediterranean

Somalia (1), Sudan (12), Yemen (5) 1,300,080 2,561 (196.98)

South East Asia Bangladesh (1), India (3), Indonesia (4), Myanmar (6), Nepal (3) 489,860 433 (88.39)

WesternPacific Cambodia (3), China (1), Papua New Guinea (4), Philippines (3), Viet Nam (6)

2,795,890 657 (23.49)

Introducing innovative solutionsSAPELs introduced several innovative solutions

for delivery of MDT drugs to patients. For example, in areas with no health care facility or where patients were unable to contact the health facility regularly, MDT drugs were provided either to a community leader or a family member (lay-supervised treat-ment). In some projects, patients were given more than one month’s supply of drugs so that treatment could be continued without interruption (self-super-vised treatment).

Lay-supervised treatment was adopted in some projects in Brazil (Jurua and Purus rivers), Chad (Kyabé and Am-Timan districts), Congo (Cuvette region), India (Raipur district), Nigeria (fishing communities in Akwa Ibom state), Sudan (Rashad province, Mabaan, Terkaka and Roken areas) and Yemen (Abiyan Governorate and Sayhoot district). Local community leaders, teachers and community health agents (volunteers) were given a brief ori-entation by the health care worker on the obvious signs of leprosy, its complications and treatment. These individuals in return helped the elimination programme by identifying and referring suspected cases of leprosy, delivering MDT drugs to patients and supervising treatment. In some of these projects, community leaders were provided with a full course of treatment for distribution to patients. Through SAPELs, MDT drugs could therefore be delivered in a similar way to that in Accompanied-MDT, which was recommended by WHO in 2000.

Self-supervised treatment was used in some projects for patients living in conflict zones or for those belonging to nomadic or migrant population groups. In these situations, patients were provided with information about treatment and where to report in case of developing complications. For example, projects carried out in Côte d’Ivoire (among Libe-rian refugees in Danane, Guiglo and Tabou health districts), Nepal (remote areas in Jumla district),

Sudan (insecure areas of Maban Jabel, Marra and Torit regions) and Yemen (among nomads from Al-Abar, Al-Saeeid, Meifa’a, Nisab, Sayhoot and Hagar districts), patients were given 3 to 12 months’ supply of MDT drugs to cover the period until their next contact with a health care worker.

Without such innovative approaches, most cases detected under SAPELs would have had difficulties completing the full course of treatment as a result of their inability to contact health services in the months following detection and the health service being unable to contact them.

Improving access to treatmentSAPELs in Brazil (Upper Negro River in Amazon

region), Congo (Cuvette region), Democratic Republic of the Congo (Kimpese and Kwango areas), Madagascar (Iakora prefecture), Mali (Douentza, Koro, Tenekou and Youwarou areas), Myanmar (Khanti and Paletwa townships), Nepal (Dolkha, Jumla and Sankhuwasabha districts), Somalia (lower Jubba and Shabelle regions), Sudan (Jabal Marra, Mabaan, Rashad, Rokon, Terekeka and Torit areas and Abeie province) and Yemen (Abiyan governorate and Al-Abar, Thamood and Hagar districts) provided training to health workers from local health care facilities who were not previously involved in leprosy work.

In addition, technical guidelines, educational materials and stocks of MDT drugs were also pro-vided. As a result, MDT services were integrated in more than 250 health facilities. In these project areas, once the mobile teams had made an initial diagnosis, patients were entrusted to the trained health care worker for continuation of treatment from the integrated health care facility.

Through integration, the number of health care facilities providing MDT services has increased considerably, helping to improve geographical


29

coverage for the national programme. In addi-tion, as new treatment centres were integrated, it became possible to sustain MDT services even after completion of the project.

Extension into other areasA successful SAPEL in China (Yunan province)

resulted in the launch of a similar project in Simao prefecture aimed at integrating leprosy services with the primary health care system. Similarly in Viet Nam (Lam Dong province), the project was extended to cover the remaining six districts to pro-vide MDT services to minority population groups.

Community participationThe success of SAPELs in Brazil (Jurua River

in Acre state), Cambodia (Kampong Speu, Kam-pong Cham and Koh Kong provinces) and Indo-nesia (Waropen Atas in Irian Jaya and Kepulauan Riau district of Riau province) was attributed to the involvement of community leaders (village chiefs, religious leaders and school teachers).

These individuals helped to mobilize the commu-nity and provided logistic support to enable health care workers to carry out various assigned activities in the villages and wards without difficulty.

Many local organizations also actively par-ticipated by providing logistic support and help to the mobile teams in carrying out information ses-sions, for example in Brazil (Purus river), Nepal (Sankhuwasabha district) and the Philippines (Abra Island).

Curing patientsNational authorities conducted a follow-up of

cases detected during SAPELs (Table 17). Because of the difficulties in undertaking such an exercise,

only a few projects were able to collect data on cure rates. The low cure rates, especially for multi-bacillary cases reported from Brazil (Purus river), Indonesia (Waropen Atas) and Yemen (Thamood, Al-abar, Hagar and Dowan), were mainly due to the short interval between starting treatment and the follow-up exercise, particularly for patients who had begun treatment with MDT towards the end of the project.

Lessons learned

Sustaining activitiesSAPELs were successful in highlighting the

need to extend MDT services to areas where health care infrastructures were previously either weak or non-existent. However, some projects were implemented as an extension of the ongo-ing routine programme and as such incorporated a large number of specialized elements. In some instances, for example in Brazil, biopsies were taken for confirmation of diagnosis.

In certain projects, very few local health care workers were involved, and specialized health care workers from outside the area carried out most of the work. Although projects were successful in diagnosing disease and treating cases who would never have had an opportunity to be treated and cured, sustaining project activities is a major chal-lenge that requires careful planning.

Some SAPEL areas experienced a sudden flare-up of civil conflict that destroyed activities already begun by projects. Mass population movements, loss of trained health care workers and the destruc-tion of MDT drug stocks and patient registers made it difficult for national programmes to maintain any disease control activities in such areas.

Table 17. Cure rates among newly detected cases in SAPEL areas

Area and country Project Period Date of follow-up

No. of Cases Detected PBa

CureRate %

MBb

CureRate %PB MB Total

Brazil (Jurua river) Feb 1995– May 1996 Jun 1998 10 9 19 90 67

Brazil (Purus river) Feb 1996– May 1997 Nov 1997 11 6 17 46 -

China (Mengzhe and Menghai township) Jan 1996– Jan 1997 Oct 1997 22 25 47 100 100

India (Abujhmad, Bastar district) May 1996– May 1997 Jun 1998 18 11 29 72 64

Indonesia (Waropen Atas) Jun 1996– Jun 1997 Oct 1997 50 17 67 68 12

Sudan (Rokon, Equatoria state) Apr 1996–Dec 1996 Dec 1997 127 44 171 76 95

Yemen (Al-Mahara, Sayhoot) Apr 1996– Mar 1997 May 1998 25 27 52 92 96

Yemen (Thamood, Al-abar, Hagar and Dowan, Hadramout) Nov 1996– Mar 1998 May 1998 69 32 101 77 34

Notes: a Paucibacillary leprosy b Multibacillary leprosy


30

MDT services are being expanded in South Sudan and Somalia in collaboration with various NGOs working in these conflict zones. WHO contin-ues to provide support for training of health workers, MDT drugs and technical guidelines. The Guide to Eliminate Leprosy is being translated and printed in the Dari language for use in certain regions of Afghanistan with the help of an NGO working in the country.

In South Sudan a total of 12 NGOs are partici-pating in providing MDT services through the col-laborative mechanism of Operation Life-line Sudan (South). Due to the prevailing security conditions in the field differentiation between previously treated patient and new could not be properly carried out and as such all cases diagnosed with leprosy were put on MDT so as to provide these patients with the best possible treatment.

In Somalia, six NGOs are collaborating with WHO in providing MDT services mainly in Bani-dar, Shebelle, Juba, Bay, Bakool, Gedo and Hiran areas.

When implemented appropriately, the leprosy elimination strategy prevents the transmission of the disease and the development of secondary cases. To facilitate the leprosy control programme in the southern sector, WHO has provided technical training, guidance and free drugs to all partners who implement MDT. The diagnosis and classification of leprosy has been simplified and no longer requires laboratory expertise as it is based on a specific set of clinical physical findings.

The objective of this simplification in diagnosis and classification is to train health workers at the PHCC level in early detection and treatment of lep-rosy. Treatment of leprosy patients in the southern sector began in 1960 in Bahr el Ghazal when Catholic missionaries established two leprosaria at Kuelkwac (near Wullu) and Pagarau. With the expulsion of all religious workers from the country in 1964, both of these facilities were destroyed and the leprosy patients scattered.

Today, the majority of leprosy patients are still treated by Catholic missionaries through the Dio-cese of Rumbek (DOR) and the Comboni Sisters working in the Tambura/Yambio Diocese (DOTY). The DOTY operates a mobile outreach programme with trained Sudanese health workers visiting sites in Tambura, Yambio and Maridi Counties for distri-bution of appropriate medications and diagnosis of new cases. The DOR programme is implemented

UN Special InitiativeCost-effectivenessSAPEL implementation costs ranged from US$

5,000 to US$ 20,000 depending on the country, area and duration of the project. Although the project goal was to promote equity in health care, cost-effective-ness comparisons were difficult because each project was conducted under very different economic, social, geographical and political conditions. Certain extra costs to reach such patients are justifiable if leprosy is to be eliminated in all areas and the possible ben-efits of improving health care access in these areas are to be taken into consideration.

Absence of pockets of high endemicityIn all SAPELs, the number of new cases detected

was more or less within the expected range. None of the projects had unexpectedly large numbers of new cases. This outcome was very encouraging, demonstrating that national programmes have in general covered most of the known, highly endemic areas. SAPELs have therefore shown that these dif-ficult-to-access areas do not harbour large numbers of undetected cases, which could have seriously underestimated the magnitude of the problem.

However, some projects did report large num-bers of new cases. For example, in Abeie province of Sudan, 340 new cases were reported, of which 30% had grade 2 disabilities. It is possible that many of these new cases were former dapsone-treated cases that were re-registered as new cases due to loss of records and registers.

ConclusionSAPELs were able to sensitize national pro-

gramme managers to the needs of uncovered and difficult-to-access areas in their programmes. Additional resources provided through such projects have helped to improve leprosy elimina-tion efforts, especially in difficult-to-access areas in many endemic countries. Furthermore, SAPELs have facilitated the introduction of health care serv-ices into these areas, using leprosy as an entry point. In some areas, the process of integration with general health care services was accelerated, making it possible for patients to obtain treatment at a health care facility nearer to home.

For practical reasons, most projects modified the standard way of delivering MDT drugs to patients by providing drugs in a flexible way, enabling patients to continue treatment without interruption and to be cured. The success of some SAPELs has motivated national programmes to incorporate certain activities — such as involving the community in leprosy work, integration of MDT services and providing MDT drugs in a patient-friendly way — as part of their routine leprosy elimination activities in the field.


31

by various religious congregations and supports seven facilities for care and treatment of leprosy patients. In addition, in agreement with the Nippon Foundation, WHO has secured resources for inten-sified activities over a three year period (2003-2005) in three countries in the African Region: Angola, Madagascar and Mozambique.

Ongoing research efforts

Research on the epidemiology of leprosy is limited by the problems associated with a low- incidence disease, the long incubation period and the lack of relevant tools. Serological tests for anti-bodies to Mycobacterium leprae PGL1 have been extensively characterized in endemic settings. Rapid simple assays are being evaluated in the field. Attempts are under way to identify antigens suitable for use as improved skin test reagents. These are undergoing initial evaluation in Brazil and Nepal. Recombinant proteins and synthetic peptides are also being investigated as potentially specific antigens in blood-based tests to measure T-cell responses to M. leprae as an indicator of infection.

Efforts are under way in a few laboratories to identify genetic polymorphism as the basis for development of strain-typing systems for M. leprae. Variations in short tandem repeat loci appear par-ticularly promising.

A range of research efforts addressing nerve damage is currently being undertaken. These have been largely uncoordinated in the past but recent developments have led to more coordinated efforts. Work is in progress in basic sciences studying the mechanisms of neurotropism and the pathogenesis of nerve damage. A number of epidemiological studies have provided an important understanding of the risk factors for nerve function impairment and reactions. Several clinical trials of interventions for prevention and treatment of reactions, based on new regimens and new drugs, are nearing comple-tion in Bangladesh, India and Nepal.

Research opportunitiesThe availability of M. leprae and other mycobac-

terial genome sequences provides important oppor-tunities for identification of novel M. leprae-specific antigens that can be used for the development of improved tests for infection. Sequence information is also central to prospects for the development of molecular epidemiology approaches for leprosy. Leprosy research is also well placed to benefit from the rapid advances in post-genome technologies

such as microarrays and bioinformatics.

Research on transmission is particularly timely given the current epidemiological situation, with MDT reducing the prevalence and the rate of new case detection showing a confusing trend of stable or increasing levels.

The genome project provides a specific research opportunity to explore neurotropism in leprosy. New Schwann cell models of M. leprae infection provide opportunities to investigate the basic mechanism(s) of nerve damage in leprosy. New therapeutic oppor-tunities are available based on a new generation of immunoregulatory drugs and TNF-α inhibitors. The development of standardized outcome measures, as a result of recent clinical trials for both nerve function and reactions, provide opportunities for new clinical studies.

Transmission To sustain current successes and to approach

the goal of eradication of leprosy, there is a need to identify new intervention strategies that complement MDT by targeting the reduction of transmission.

Nerve damageAlthough MDT has had a dramatic impact on

global prevalence, there are still two to three mil-lion people with deformities worldwide. In addition, in many parts of the world its impact on rates of detection of new cases is unclear. Although a limited number of new cases will continue to occur in the coming years, these new cases will remain at risk of developing nerve impairment. Thus detecting, man-aging and understanding the mechanisms involved in nerve damage remain a high priority. Trials of prophylaxis and treatment of nerve damage have not provided optimal approaches for the prevention and management of nerve impairment. Therefore a combination of clinical and epidemiological research studies is required for the identification of risk factors, management and prevention of nerve damage.

Research to improve integrationIn most leprosy-endemic countries, leprosy

control activities have been integrated into the general health services or are in the process of being integrated.

Major advantages of integration are increased accessibility to diagnosis and treatment, and decreased stigma attached to the disease, with increased levels of sustainability and cost-effec-tiveness. Regimens that shorten the duration of treatment and that are uniform for all patients will considerably simplify the administration of treat-ment by the general health services.

Global Research


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TAG Meeting 2003The fifth meeting of the WHO Technical Advi-

sory Group on the Elimination of Leprosy (TAG) was held in Yangon, Myanmar, in February 2003. The main conclusions and recommendations are summarized below.

• TAG acknowledges that the majority of countries where leprosy was considered to be a public health problem have now attained the goal of elimination at the national level. However, an analysis of the current global leprosy situation indicates that a few major endemic countries (nota-bly Brazil and India) are likely to miss the goal of elimination at the national level by the end of 2005. TAG recommends that WHO should play a key role in reviewing their plans of action for the coming years and, where necessary, assisting in develop-ing more focused plans in order to reach elimination as early as possible.

• TAG members expressed their satisfaction that many countries have reached the elimi-nation goal, in spite of many constraints, byusingflexibleapproachesthatarebothinnovative and cost-effective. The experi-ences from such countries will motivate other disease control programmes within the countries themselves and also national programmes in other countries that are cur-rently lagging behind. TAG urges WHO to encourage and guide countries in docu-menting their experiences and the lessons learnt for wider distribution.

• TAG notes that most of the countries that have already attained the elimination goal at national level, and have developed plans and strategies for sustaining leprosy con-trol and reaching the elimination goal at sub-national levels. WHO should, where needed, assist countries in implementing such strategies.

• Concerned with the stable and high new case-detection trends observed in some major endemic countries, TAG recom-mends that WHO should develop proto-cols to undertake studies for analysing and validating case detection, as reported by routine information systems. Such studies should be undertaken as soon as possible.

• In keeping with the urgent need in the field, and the progress made following complete decoding of the genome map of

Mycobacterium leprae, TAG recommends that WHO pursue the development of tests for leprosy diagnosis within the next two years. It also recommended that all efforts should be made to ensure that such tests areavailableforuseinfieldprogrammeswithin the next 5 years.

• TAG re-states its recommendation that leprosy elimination campaigns (LECs) are a useful approach to accelerate elimination activitiesinspecificendemicareas.How-ever, LECs should now be focused only on high endemic pockets, underserved com-munities and previously uncovered areas.

• TAG recommends that all programmes should ensure that treatment registers are periodically updated and that good registra-tion practices and guidelines are followed uniformly.

• TAG reaffirms that the use ofAccompa-nied-MDT3 would give better access to MDT for patients in general and spe-cificallyforthosewhoareunabletovisitahealth centre regularly for various reasons. Patients choosing A-MDT as their treatment option and the person accompanying them should be fully informed about the disease and treatment, including the importance of reporting promptly to the health centre in case of complications, and at the end of treatment. TAG strongly recommends that WHO prepares and distributes technical guidelines for the use of A-MDT and that countries document their experiences of its useunderfieldconditions.

• TAG strongly recommends that WHO should continue to supply high-quality MDT drugs, free of charge to all countries in need, in order to achieve and sustain elimination.

• TAG reiterates that the use of an integrated health information system for collating data on leprosy is important for the long-term, sustainable surveillance of leprosy. The minimum data requirement for monitoring leprosy at any level is the absolute number of new cases detected during a definedperiod of time.

• TAGconsidersthatvalidationorcertificationof leprosy elimination at a point of time is a verydifficultandtime-consumingexercisethat may not be relevant or cost-effective. The development of tools and approaches is technically relevant only for a disease

3 Accompanied MDT refers to the practice, already widely adopted by some countries, of providing all of the MDT required to the patient at the time of diagnosis so that treatment can be monitored by the family or community, rather than relying upon monthly supervision by specialized leprosy workers.


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Leprosy elimination is very much a success story and the disease is being progressively eliminated in a number of countries. In 2003, Côte d’Ivoire, Guinea, Myanmar and Niger were added to the long list of countries who have successfully eliminated the disease. Myanmar is a clear example of how dedicated teams, involving all health staff from the midwife to the district medical officer, can move mountains once they assume ownership for leprosy elimination. The elimination strategy hinges on improving communities’ awareness of the early signs of leprosy and, above all, their access to leprosy diagnosis and free MDT.

Leprosy is progressively moving out of the hands of a dedicated few into the hands of gen-eral health workers. Significant progress has been made towards this end with integration of leprosy into the general health services. Integration is cru-cial to ensure the long-term sustainability of leprosy elimination and is also in line with moves towards decentralization of health services in most coun-tries. In some areas, however, the implementation is being slowed down because of the reluctance of vertical teams to hand over responsibility. This needs to be urgently addressed.

An independent evaluation undertaken in 2003 in Uganda by the Initiative for Public-Private Partner-ships for Health (IPPH) highlighted how the WHO led partnership has revitalized leprosy elimination efforts. The major, widely appreciated benefit is the assurance of a sustained and consistent supply of free, high-quality drugs with no unreasonable conditionalities. There is also a strong sense of national ownership of the programmes. It is par-

ticularly gratifying to note that, contrary to general expectations, reaching the elimination target does not lead to a lack of attention to leprosy.

Although the results are impressive, there is no room for complacency. Leprosy remains a health problem in 10 endemic countries. The six most endemic countries account for about 90% of the leprosy burden. A concerted effort is needed in close collaboration with the governments of endemic countries at national and sub-national levels to urgently adapt and implement each of the main elements of the intensified elimination strategy (discussed in previous sections of this report).

There is but a small and time-limited window of opportunity to eliminate leprosy. Health priori-ties and the commitment of endemic countries are constantly changing, with diseases such as malaria, tuberculosis and AIDS, (including issues like bio-ter-rorism) diverting the bulk of all available resources for health. While this can be totally justified on public health grounds, it will still be important to ensure that leprosy remains on the health agenda so that the opportunity for its elimination is not lost.

WHO is fully committed to the elimination of leprosy and will continue to provide the necessary technical support as well as sustain the political commitment to that end, especially in countries that will require additional efforts. WHO will continue its close collaboration with health ministries and partners at the country level. Broader partnerships will help in mobilizing new expertise and additional resources for implementing innovative strategies at local level.

Leprosy elimination has had a positive spill-over well beyond the disease itself. The progressive inte-gration of leprosy into general health services is strengthening local health services as well as the confidence of health workers and communities with the availability of free and effective treatment. Lep-rosy programme managers at all levels, are being motivated by being part of a global initiative as well as sharing their experience with other programmes. The assumption of ownership by national manag-ers is particularly important for activities related to logistics, programme management and disease surveillance.

In the coming years, WHO and its partners will continue to generate and sustain political and resource commitments for leprosy. Many excellent institutions have contributed immensely towards improving care through research and train-ing in this long battle against leprosy. They will be needed now to further simplify case management, improve surveillance, strengthen socio-economic

Perspectives & Plan 2004

eradication strategy. However, the need and approaches for assessing progress with elimination of leprosy at any level are important for the programmes before, during, and after the elimination goal has been achieved. In this regard, leprosy elimination monitoring (LEM) continues to be an effective method of independently assessing leprosy elimination activities. TAG encourages further efforts to develop suitable methods for this purpose.

• Poverty alleviation measures are likely to have an impact on leprosy transmission. TAG recommends that WHO collect infor-mation on poverty alleviation measures taken in countries with a high burden of leprosy and disseminate this information to TAG members for discussion during the next TAG meeting.


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Summary of key activities to be undertaken by WHO at global, regional and country level

WHO will continue to work intensively in the 10 remaining countries with ministries of health, national programmes and NGOs to make sure that activities are intensified to achieve the elimination target by the end of 2005. WHO estimates that, provided the political situation and security are improved, at least 8 countries (out of the remain-ing 10) will reach the target by the end of 2005. The remaining two countries (Brazil and India) may need additional time to reach the target. WHO will assist these countries in reviewing their plans of action for the coming years and, where necessary, assist in developing more focused plans in order to reach elimination as early as possible.

WHO’s main activities will be:

• To coordinate the supply of high-quality MDT drugs, donated by Novartis, free of charge to all countries in need (about 80 countries), in order to achieve and sustain elimination.

• To prepare and update technical guidelines for management of a leprosy control pro-gramme, monitoring, validation, etc. Several of these guidelines have been translated into the local language and extensively distributed to the most peripheral levels.

• To disseminate information and updates on the global situation and analysis of results of special campaigns in the Weekly Epide-miological Record.

• Topreparescientificpapers,includingchap-ters for under-graduate and post-graduate text books (e.g. Manson’s Tropical Medi-cine).

• Toattendscientificmeetings.• To maintain and update a Global Website

on Leprosy Elimination.• To promote speedy integration of MDT

services (MDT services include diagnosis, treatment with MDT, patient and family counselling, community education and referral for complications) within the exist-ing general health services in all endemic countries.

• Most of the countries that have already

rehabilitation services and remain alert to counter any unforeseen challenges in the path towards the ultimate elimination of this disease during the twenty-first century.

attained the elimination goal at national level have developed plans and strate-gies, in consultation with WHO, for sus-taining leprosy control and reaching the elimination goal at sub-national level. WHO assists countries in implementing such strategies.

• To develop and implement protocols to undertake studies for analyzing and validating case detection, as reported by routine information systems. Such studies are being initiated in India and Africa.

• To promote and support Special Cam-paigns to accelerate elimination activities in selected high endemic pockets, unders-erved communities and previously uncov-ered areas.

• To coordinate the global monitoring of the leprosy situation through an analysis of country reports, consultant reports and annual statistics from Member States.

• To promote the use of a simplified andintegrated health information system for the surveillance of leprosy. LEM exercises continues to be an effective method of inde-pendently assessing progress with leprosy elimination activities, including the process of integration. WHO assists a number of countries to undertake LEM exercises.

• To organize and coordinate periodic meet-ings of the Technical Advisory Group (TAG), comprising selected experts to evaluate progress and update technical guidelines and an advocacy meeting of the Global Alli-ance for the Elimination of Leprosy (GAEL) with various partners at global and country levels.

• To coordinate chemotherapeutic research studies in more than 10 countries. These include short duration treatment using ofloxacin-based regimens, ROM single dose trial all PB cases, shortening dura-tion of treatment in both PB and MB patients using monthly doses of ROM.

• Recently, in collaboration with TDR, a new multicentricstudytoassesstheefficacyofuniform multidrug therapy (U-MDT) for all types of leprosy cases is being launched. FivefieldsiteshavebeenidentifiedinIndiato recruit at least 2 000 newly detected patients within the next 24 months. All preparations for the study are completed and recruitment of patients began in Octo-ber 2003. Interim results are expected in 2006andfinalresultsin2009.

• WHO and TDR promote the use of genom-icsindevelopingspecificdiagnostictoolsfor leprosy under field conditions.WHOhas started advocating and mobilizing

WHO activities in 2004


35

resources for this purpose, in collabora-tion with TDR and Pasteur Institute.

• Coordination of regional and country level eliminationplansandfinancialsupportforelimination activities to regions and coun-tries.

Summary of LEM and validation exercise, India 2003

The present LEM survey, which is a follow-up of a similar LEM exercise in 2002, was carried out in a standardized way across the country from the 19th May to the 13th June, 2003 and the validation of leprosy diagnosis study from 12th to 31st July, 2003 with the aim to assist decision-makers and programme managers to assess the progress being achieved towards leprosy elimination. The WHO document “Leprosy Elimination Monitoring Guidelines for Monitors 2000” was used as a refer-ence. It was adapted to meet the Indian context. The LEM survey was undertaken in the 13 high endemic states. The districts in each state were divided into two strata according to the prevalence rateofleprosy(≥&<5/10,000).Asampleof20%of the total districts in each stratum per state was considered to be representative of the state. A total of 77 districts were covered.

In 2003, the LEM monitors covered nearly 500 health facilities, of which 81% in rural areas. They interviewed 4,634 patients and 10,324 community members. The monitors reviewed 36,616 patient’s records and examined 367,174 MDT blister packs. Finally, the validation teams have seen 1,737 newly detected leprosy cases, out of the 2,541 listed by the NLEP.

The main findings of the LEM 2003 survey were

as follows:

Elimination indicators

• Prevalence and detection rates found in the LEM survey were close to those reported by the annual reports with a few excep-tions. However the reported prevalence anddetectionrateswere inflated inmostof the states included in the LEM. It was due to operational factors: wrong diagnosis, re-registration of cases, and gaps in regular cleaning/updating the leprosy registers.

• The reported prevalence compared to the prevalenceafterapplyingstandarddefini-tions was found approximately similar in many states. However, in Bihar, Chhat-tisgarh, Delhi, Maharashtra and Tamil Nadu, the reported prevalence was found significantlyhigher.

• All the states reported a prevalence/detection ratio of less than one except Delhi.

• The trends of disability grade-2 have been steadily declining in all the states over the past years. The overall proportion of dis-ability Grade-2 among new cases covered by the LEM was 1.9%. It was lower than 4% in all States, except Delhi (17%), which was due to a very high proportion (46%) of re-registered MB cases.

• The analysis of the proportion of children among new cases, along with the preva-lence and detection rates, showed that the states of Bihar, Chhattisgarh, Jharkhand and Orissa still have a relatively high level of transmission, compared to the other states.

• Overall, the proportion of MB among new cases was 37%, ranging from 17% in

Annex 1: LEM India

Leprosy Elimination MonitoringLeprosy Elimination Monitoring (LEM) is designed to identify potential problems that may hinder the provision of MDT services or retard progress towards leprosy elimination. It makes a comprehen-sive analysis of the performance of the programme through the collection of three sets of indicators, including:

• Eliminationindicators:Internalvalidityofinformationonprevalenceanddetection(crudeandspecific)and analysis of trends. This will be based on the analysis of existing information and review/updating of leprosy registers;

• The level of integration of MDT services within General Health Services: availability of MDT blister packs and geographic coverage of MDT services. This will be based on a cross-sectional survey of randomly selected health facilities and interviews of patients;

• Quality of MDT services at national, provincial, district andhealth centre levels: diagnosis, case-holding and information. This will be based on a review of individual records, leprosy registers. And interviews of individuals in communities. The quality of MDT services will be reviewed on the basis of cohort analysis.


36

Andhra Pradesh to 60% in West Bengal. These figureswere affected by the highproportion of re-registration of MB cases in some states, especially Karnataka (65%), Delhi (46%), West Bengal (39%) and Bihar (22%).

• Regarding the proportion of females among newcases, theLEMfindingsshowedanaverage of 35%, with wide differences among the 13 states (from 23% in Delhi to 45% in Andhra Pradesh). No epidemio-logical reason can explain these variations. Level of awareness among female, vary-ing from state to state, might be a factor; but this would need to be further investi-gated.

• The New Case Detection Rates (NCDR) among Scheduled Caste and Scheduled Tribe compared with NCDR among non ST and non SC population, was higher in many states, with possibility of a higher risk among SC and ST or special detection activities targeted among these groups.

Integration of MDT services• The diagnosis of leprosy was being made

and treatment initiated at 75% of the health facilities visited, which provided these serv-ices on all working days in 67% of health facilities.

• The median distance to collect MDT was 3.1 km and median travel cost was Rs. 5.9.

• Accompanied MDT was provided as an option for patients who needed more than one month of treatment in 57% of health facilities, with wide variations from 4% in West Bengal to 97% in Bihar.

• In 92.2% of health facilities, the leprosy register was maintained. In 92.4% the drug register was maintained by the pharmacist at the health facility itself.

• The status of MDT stock, in patient-months, in various health facilities was 4.0 for MBA, 5.8 for MBC, 3.5 for PBA and 4.5 for PBC, but wide variations were observed. On fur-ther analysis, only 20% of health facilities had 3 months MDT stock of all categories of blister packs, in relation to the number of registered cases.

• MDT drugs are available but adequate dis-tribution of MDT blister packs in relation to the caseload at health facilities was a major issue.

• Although the integration process was observed to have started in almost all the states, yet the level of integration was vary-ing from state to state.

As per the present LEM survey, states could be classified into three categories, according to their integration performance:

• Good integration performance: Bihar, Delhi, Jharkhand, Orissa, Tamil Nadu, Uttar Pradesh and Uttarranchal;

• Average integration performance: Chhat-tisgarh, Karnataka, Madhya Pradesh and Maharashtra;

• Poor integration performance: Andhra Pradesh and West Bengal.

Quality of MDT Services

• As per the records maintained at health facilities visited by the monitors nearly all the newly detected leprosy cases were put on MDT.

• The overall cure rate after assessment of cohort analysis of the leprosy cases was 83.7% for MB and 94.1% for PB. The MB cure rate was below 80% in Bihar and Jharkhand and only 63% in West Bengal. The PB cure rate was above 90% in all States, except in Delhi (74%).

• The overall defaulter rate was 10.1% for MB and 3.5% for PB cases. The MB defaulter rate was high in Delhi (34%), Bihar (18%), Jharkhand (17%), and West Bengal (10%).

• It was observed that nearly 5% of MB cases and 1.8% of PB cases continued treatment evenaftercompletingfixeddurationMDT.

• The proportion of MB cases continuing treatment after 12 months was found of 20% in Delhi, 11% in Uttaranchal and 7% in Chhattisgarh.

• The proportion of health facilities with no discrepancy of new leprosy cases between treatment register and annual report was 50.6% whereas 29.4% and 20.0% of health facilities mentioned over reporting and under reporting respectively.

• At the district stores, the proportion of MDT packs not damaged and not expired was 95.4% for MBA, 80.3% for MBC 95.1% for PBA and 84.5% for PBC. High propor-tion of damaged and expired drugs was reported from Tamil Nadu, Orissa and West Bengal.

• At health facilities level, proportions of MDT packs of good quality were 98.7% for MBA, 94.6% for MBC, 97.5% for PBA and 90.8% for PBC. High proportion of damaged/expired drugs was found in Bihar and West Bengal.


37

Implementation of the Simplified Information System (SIS)

• In 31.5% of health facilities SIS guidelines were available, 65.7% had new SIS patient cards, and 67.7% had new SIS treatment registers, 63.2% new SIS MDT drug regis-ters and in 78.6% new SIS MDT monthly report formats were available.

• The proportion of health facilities where the last monthly report was sent on new SIS format was 74.3%.

• Only 29% of health facilities were found with at least three NLEP indicators calculated.

• The objective of using data for monitoring and decision making of the SIS is not yet fully operational at district and health facility level.

Leprosy awareness in Community

• It was observed that 63% of the community members interviewed could tell at least one sign/symptoms of leprosy.

• Nearly 62% of the community members knew that leprosy is curable and 63% knew that treatment is available free of charge.

• But only 19% of the community member could tell the correct cause of leprosy.

Validation of Leprosy Diagnosis

• Out of the 1503 newly detected leprosy cases examined by the validators, the proportion of cases which were wrongly diagnosed as leprosy was 9.4% (11.7% for PB and 7.1% for MB cases).

• Out of the 1737 cases seen by the valida-tors, the proportion of re-registered cases was 13.5% (6.8% for PB and 19.6% for MB cases).

• The proportion of wrong grouping was 11.2% (4.2% for PB and 18.3% for MB cases).

• Nearly 5.0% of the leprosy cases were non-existent (fake cases).

Recommendations

1. Improve the quality of the leprosy diagno-sis and grouping at health facility level, by strictly applying standard procedures for testingtheskinsensorydeficitandnervethickening.

2. Every newly detected case should be asked

questions about potential MDT treatment in the past, to avoid re-registration of cases.

3. The leprosy register should be updated monthly, at the time of reporting, thus deleting patients according to the standard definitions.

4. Enhance the MDT coverage in rural and urban areas (including slums) by making MDT services available through all func-tioning health facilities and on all working days.

5. Enhance the case detection among female, especially in the states where the female detection ratio is low.

6. Improve the MDT stock management at health facilities by regular indent based on the case load for all categories of blister packs to prevent drug excess, shortage, damaged and expired MDT blister packs. Use the new Government of India guide-lines on MDT stock management.

7. Re-deploy excess of MDT to other blocks/districts, based on the patient-months indi-cator and destroy expired MDT drugs.

8. All the personnel involved in leprosy control activities should follow the Government of IndiaGuidelines on fixed durationMDTtreatment (12 doses for MB and 6 doses for PB cases)

9. Ensure the completion of treatment for all patients under MDT, especially in Delhi and large urban areas. Patients likely to be irregular should be provided with the option of Accompanied-MDT.

10. Adequate counselling of patients, espe-cially at the time of diagnosis and initiation of treatment, should be promoted.

11. Ensure that all the SIS document and formats are available and used at health facility and district levels.

12. Improve the completeness, timeliness and accuracy of reporting.

13. District managers should regularly monitor the leprosy programme through essential SIS indicators and provide feedback to the block level.

14. Increase the awareness of leprosy among communities by strengthening inter-per-sonal approach.


38

MDT supply by country in 2003

Table 11 that follows provides a regional sum-mary of MDT that was supplied to countries by WHO in 2003. This table does not include the smaller emergency shipments made from the WHO buffer stock held in Geneva, whcih are shown separately in Table 17. Tables 12 to 16 show shipments grouped by individual country within the African Region (AFRO), the Americas (AMRO), East-ern Mediterranean (EMRO), South East Asian (SEARO) and Western Pacific (WPRO).

Note that in some cases, countries received more than one order, whilst in others there were multiple, partial shipments within each order. Large orders (e.g. to India and Brazil) were split into sev-eral shipments over the whole year.

Table 18: MDT Supply to countries in the African Region (AFRO) in 2003

Country WHO Order

MB Adult

MB Child

PB Adult

PB Child

Angola 03/16628 34,560 3,456 9,504 8,640

Burkina Faso 03/01868 4,608 0 864 0

Burundi 03/01256 2,880 0 0 0

Cameroon 03/01884 3,456 576 0 864

Central African Republic

03/14722 4,608 144 240 144

DR Congo 03/01272 16,128 2,880 11,232 0

DR Congo 03/01922 21,888 0 4,320 0

Equatorial Guinea

03/02155 240 48 96 48

Ethiopia 03/15257 49,536 4,608 5,184 1,728

Gabon 03/02040 576 96 240 144

Gambia 03/02201 576 96 240 96

Ghana 03/02074 12,672 1,152 1,152 144

Guinee 03/01302 9,216 1,152 1,728 0

Kenya 03/01396 2,304 0 0 0

Liberia 03/01400 3,456 576 864 0

Madagascar 03/02082 25,344 2,304 0 0

Malawi 03/02104 2,304 192 1,728 432

Mali 03/01426 5,760 576 2,592 864

Mozambique 03/02171 2,880 0 0 0

Mozambique 03/10484 58,752 2,304 12,096 2,592

Niger 03/02163 288 288

Nigeria 03/01442 50,112 4,032 1,728 0

Senegal 03/01485 4,608 0 864 0

Sierra Leone 03/02112 1,344 192 48 48

Tanzania 03/01523 46,080 1,728 8,640 0

Togo 03/01531 3,072 96 0 0

Uganda 03/02139 2,832 48 0 0

Zambia 03/01914 0 240 2,112 48

Totals: 369,792 26,784 65,472 16,080

Annex 2: MDT supply 2003 and plans for 2004Table 19: MDT Supply to countries in the American Region (AMRO) in 2003

Country WHO Order

MB Adult

MB Child

PB Adult

PB Child

Argentina 03/01833 2,880 0 864 0

Argentina 03/16369 5,760

Bolivia 03/01248 816 96 96 48

Brasil 03/01850 236,160 15,552 152,064 15,552

Brasil 03/07955 108,288 24,768 50,112 23,328

Colombia 03/02180 2,880 0 1,728 0

Colombia 03/12886 16,704 1,728

Cuba 03/02198 1,728 0 864 0

Cuba 03/18558 3,360 96 672 192

Dominican Republic

03/01892 1,056 48 0 48

Guyana 03/02058 288 96 96 96

Haiti 03/01906 1,056 96 768 96

Honduras 03/01329 288 48 48 48

Paraguay 03/01469 5,712 48

Venezuela 03/02147 2,304

Totals: 389,280 40,800 209,088 39,408

Table 20: MDT Supply to countries in the Eastern Mediterranean Region (EMRO) in 2003

Country WHO Order

MB Adult

MB Child

PB Adult

PB Child

Afghanistan 03/01230 576 144 432 0

Egypt 03/01299 15,552 0 864 0

Pakistan 03/18540 8,976 240 624 240

Somalia 03/01493 1,728 240 96 96

Sudan 03/01515 11,520 0 4,320 0

Sudan (South) 03/02066 8,064 1,728 288 288

Yemen 03/01825 6,912 720 2,592 384

Totals: 53,328 3,072 9,216 1,008

Table 20: MDT Supply to countries in the South East Asia Region (SEARO) in 2003Country WHO

OrderMB

AdultMB

ChildPB

AdultPB

Child

Bangladesh 03/01841 30,528 0 9,504 4,320

Bangladesh 03/10760 5,760

India - Madras 03/01337 44,928 120,096

India - Hyderabad

03/01345 29,376 90,720

India - Karnal 03/01353 50,112 123,552

India - Calcutta 03/01361 44,928 123,552

India - Bombay 03/01370 50,112 123,552

Indonesia 03/01388 126,720 8,640 8,640 0

Indonesia 03/24558 60,480 9,792 19,008 2,592

Nepal 03/01434 89,856 0 34,560 0

Nepal 03/03666 4,608 6,048 6,048

Sri Lanka 03/01507 11,520 0 3,456 0

Sri Lanka 03/19643 10,368 4,032 10,368 6,912

Totals: 336,960 255,168 91,584 601,344


39

Table 22: Global Summary MDT Supply in 2003Country MB

AdultMB

ChildPB

AdultPB

Child

Africa (AFRO) 369,792 26,784 65,472 16,080

Americas (AMRO) 389,280 40,800 209,088 39,408

Eastern Mediterranean (EMRO)

53,328 3,072 9,216 1,008

South East Asia (SEARO) 336,960 255,168 91,584 601,344

WesternPacific(WPRO) 82,944 4,800 7,392 1,728

Totals: 1,232,304 330,624 382,752 659,568

Table 21: MDT Supply to countries in the Western Pacific Region (WPRO) in 2003

Country WHO Order

MB Adult

MB Child

PB Adult

PB Child

Cambodia 03/01876 3,456 768 480 0

Cambodia 03/18159 3,456

China 03/01264 9,216 0 864 0

China 03/01264 9,792 0 0 0

Malaysia 03/01418 4,608 0 864 0

Papua New Guinea

03/14749 576 576 1,728 864

Philippines 03/01477 22,464 2,880 864 0

Philippines 03/01477 21,888

Viet Nam 03/15940 7,488 576 2,592 864

Totals: 82,944 4,800 7,392 1,728

Table 24: Use of Geneva buffer stock in 2003Country Port of Entry MB

AdultMB

ChildPB

AdultPB

Child

Argentina AMRO 1,152 864

Afghanistan EMRO 1,728 192 480 96

Guyana AMRO 672 96 96 96

Comores AFRO 2,592 864

Gambia AFRO 48 48

Sierra Leone AFRO 240

Colombia AMRO 240

Cambodia WPRO 576 480

Burundi AFRO 288 288

Dominica AMRO 48 48

South Sudan EMRO 576

Bangladesh AMRO 576

Uganda AFRO 98 480 96

Mozambique AFRO 576 864

Paraguay AMRO 144

South Sudan AFRO 96 288 96 96

CAR AFRO 576 96 240 96

PNG WPRO 0 96 864 192

Vietnam WPRO 480 480

Cambodia WPRO 1,200 528

DR Congo WPRO 1,008 96 768 96

Cape Verde AFRO 288 48 48 48

Angola AFRO 8,640 2,592

Paraguay AMRO 1,728

Burkina Faso AFRO 576 1,440 288

Dominican Republic

AMRO 2,304

Cape Verde AFRO 288 48 48 48

Sierra Leone AFRO 2,304 576 1,728 864

Zambia AFRO 96 96

Ecuador AMRO 96 192 96

Swaziland AFRO 48 48 48 48

Chile AMRO 48 48 48 48

Eritrea AFRO 1,152 96 1,344 192

CAR AFRO 5,184 576 2,352 240

Mexico AMRO 4,032

Totals: 31,296 6,674 17,568 6,528

Geneva Buffer receipts 41,472 10,032 18,144 10,368

Table 23: Supply of loose clofazimine in 2003Country CLO 50mg CLO 100mg

Bangladesh 5,000 10,000

Pakistan 3,000 10,000

Viet Nam 1,000 6,000

Sudan 2,000

Trinidad & Tobago 1,000 500

Guyana 1,000 4000

Viet Nam 5,000 20,000

Sudan 1,000 4,000

Sri Lanka 2,000 19,000

Malaysia 1,000 10,000

Lao PDR 1,000 10,000

St Lucia 500

Angola 5,000 20,000

Jamaica 1,000 1,000

Trinidad & Tobago 2,000 2,000

New Zealand 1,000 500

Cambodia 20,000

Tanzania (pending) 2,000 25,000

Totals: 32,000 164,500

Receipts

IDA Netherlands 325,500

Geneva 50,000 224,500

Totals: 50,000 550,000

Table 25: Summary of planned MDT supplyin 2004 by WHO Region.Country MB

AdultMB

ChildPB Adult PB

Child

Africa 258,672 22,656 66,672 21,408

Americas 286,656 19,344 24,672 10,464

East. Mediterranean 36,384 3,024 7,296 2,160

South East Asia 446,976 32,448 1,646,544 258,672

WesternPacific 46,848 2,784 3,936 1,392

Totals: 1,075,536 80,256 1,749,120 294,096

leprosy elimination project status report 2003 · who leprosy elimination project: status report...

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