Eliminating Leprosy Needs Renewed Efforts, Greater Push

02/02/2015 8:16 AM IST | Updated 15/07/2016 8:24 AM IST
Robertus Pudyanto via Getty Images
SURABAYA, INDONESIA - JANUARY 29: Umar, 33, a former leper plays chess at Babat Jerawat Leprosy Shelter on January 29, 2014 in Surabaya, Indonesia. Leprosy remains a largely neglected disease, especially in the rural areas of the country where little is known about it and many suffer from the stigma and lack of knowledge surrounding the disease. Indonesia has around 25,000 leprosy sufferers, 30 % of them in East Java Province, giving it the third highest number of cases in the world behind India and Brazil. (Photo by Robertus Pudyanto/Getty Images)

The elimination of leprosy as a global public health problem in the year 2000 was a significant milestone in history. Though the prevalence has come down to less than one case per 10,000 population globally, new cases are being reported from more than 100 countries. As per the leprosy statistics published by WHO in 2014, 215,656 new leprosy cases were detected worldwide. The WHO South-East Asia Region alone contributed 155,385 cases, 72% of the global leprosy case count. Leprosy is not uniformly distributed across the world; 96% of cases are limited to 15 countries, which report more than 1000 new cases annually. Even in these countries, high leprosy prevalence is recorded in certain endemic pockets, usually referred to as "hotspots". A small proportion of patients with visible deformities in their hands, feet and eyes due to delayed detection, experience stigma associated with disfigurement.

Globally, 13,289 such new cases with visible deformities or grade 2 disabilities were detected in 2013. One in every 10 new leprosy patients is a child and, worldwide, there were 19,796 new cases of leprosy found in children. This fact needs greater attention, as it causes childhood disabilities not unlike polio. These numbers are totally unacceptable and call for a review of leprosy programs. We need to focus on the remaining leprosy "hotspots" with renewed vigour. An efficient treatment protocol for leprosy was introduced by WHO in the early 1980s. There is no reason why a person should suffer deformities and stigma from leprosy today.

One of the oldest diseases known to humanity, leprosy is still attributed to causes like the curse of God and the result of past sins and so on. Occasionally, instances of affected persons being separated from their families and isolated in a remote place or an island are reported, albeit, in small numbers.

The stigma attached to the disease and low levels of awareness in the community are deterrents to the early detection and treatment of leprosy, which is the only time-tested way to completely bring leprosy cases down to zero. An untreated patient is a source of infection. Leprosy transmits to a healthy individual through air or skin-to-skin contact with an infected person. It takes several years for a susceptible person to acquire the disease. The earliest symptom of leprosy is a skin patch and loss of sensation. In the absence of any discomfort at the outset, an affected person tends not to report the patch.

WHO introduced the multidrug therapy (MDT) in the early 1980s as the main treatment protocol. MDT has multiple benefits - the infected person ceases to be infective with a single dose; it is a complete treatment for leprosy; and it reduces the risk of disabilities and consequent stigma. MDT eventually reduces treatment costs on the health system. Over 16 million patients from 125 countries across the globe have been treated with MDT, which helped rapidly reduce the prevalence of the disease to less than one case per 10,000 population at national levels. As of today, the MDT regimen stands as a robust protocol. In addition, WHO makes MDT available free of cost in all countries.

Now that the number of leprosy cases has come down from 11 million in 1983 to under a quarter million, we need to renew our commitment in order to completely eliminate this disease from the world.

It is time for the leprosy programmes to re-energise their focus on the remaining endemic areas or "hotspots". Detection of leprosy in children is evidence of continued transmission of the disease in the community, while grade 2 disabilities indicate delayed detection of the disease. We now need to work towards zero child cases with visible deformity or grade 2 disability by 2020. We also need to detect all new leprosy cases before disability. Focused case-finding activities should be rolled out in these areas for early detection of cases and complete treatment with MDT; they still are the basic tenets of leprosy control. Breaking the chain of transmission between the patients and healthy population remains 'the strategic choice' for controlling leprosy.

Also, there is need for further research. Resistance to antimicrobials, particularly rifampicin, is an imminent risk. Though the frequency is low as per the available data, its impact on the success of MDT could be substantial. Recognising the need, WHO spearheaded an initiative of developing a network of sentinel centres to monitor the occurrence of drug resistance to leprosy in all leprosy-endemic countries. Till now, the results from the sentinel centres are very encouraging. The incidence is low and WHO believes in continuing such surveillance to sustain the gains achieved by MDT in controlling leprosy.

Globally, more than 200,000 new cases have been detected every year for the past five years in spite of leprosy control efforts. To overcome the challenges in reducing the occurrence of new cases, health ministers from 17 endemic countries committed to the Bangkok Declaration in 2013 which re-affirmed political commitment and urged countries to enhance efforts to reach the unreached populations. The Bangkok Declaration also includes leprosy-affected persons in leprosy-control activities - those affected by leprosy are a great resource; their involvement helps in early case detection and reduction of stigma.

WHO is now developing a new global leprosy strategy for 2016-2020 to detect all cases before disability and achieve zero disability cases among children. The Nippon Foundation, Novartis Foundation for Sustainable Development (NFSD), International Federation of Anti-leprosy Associations (ILEP) and the networks of persons affected by leprosy are joining forces to support the leprosy programme with funds and MDT supply until 2020. These programmes are receiving additional support from NGOs at the national and sub-national level.

Every person has a role to play in reducing the disease burden of leprosy and removing this age-old scourge from the planet. We need to enhance awareness about the early signs of the disease, make MDT available and encourage acceptance of the affected at home, school or at the workplace. These coordinated efforts would improve early case detection and help us reach the goal of zero child cases with visible deformity or grade 2 disability by 2020.

All figures are based on WHO studies.

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