TMIH572

Tropical Medicine and International Health

volume 5 no 6 pp 388399 june 2000

Review: Mycobacterium leprae millennium resistant!

Leprosy control on the threshold of a new era
Jan Visschedijk1, Jacques van de Broek1, Henk Eggens1, Peter Lever1, Stella van Beers2 and Paul Klatser2

1 Department of Health Care and Disease Control, Royal Tropical Institute, Amsterdam, The Netherlands
2 Department of Biomedical Research, Royal Tropical Institute, Amsterdam, The Netherlands

Summary Over the past decades, the conditions of leprosy control implementation have changed dramatically.
Introduction of multidrug therapy, together with the global effort of the World Health Organization to
eliminate leprosy as a public health problem, had a tremendous impact on leprosy control, particularly by
decreasing the registered prevalence of the disease. At the beginning of the new millennium, leprosy control
programmes face several new challenges. These relate not only to changes in the prevalence of the disease,
but also to changes in the context of leprosy control, such as those created by health sector reforms and
other disease control programmes. This review discusses current knowledge on the epidemiology of
Mycobacterium leprae and some important aspects of leprosy control. It is argued that our understanding is
still insufficient and that, so far, no consistent evidence exists that the transmission of leprosy has been
substantially reduced. Sustainable leprosy control, rather than elimination, should be our goal for the
foreseeable future, which also includes care for patients on treatment and for those released from treatment.
This, however, requires new strategies.

keywords leprosy control, leprosy elimination

correspondence Jan Visschedijk, Royal Tropical Institute, Health Care and Disease Control,
Wibautstraat 137J, 1097 DN Amsterdam, The Netherlands. E-mail: j.visschedijk@kit.nl

Introduction
Throughout history, leprosy has been characterized as a disease
responsible for serious deformities and disabilities resulting in
stigmatization and psychological and social suffering. Though
leprosy has been prevalent in most parts of the world, it
vanished in several areas, including northern Europe, long
before an efficacious treatment was developed. However, at the
end of the 20th century, leprosy was still endemic in many
developing countries, particularly affecting the poorest
segments of these societies. Every year more than half a
million people are diagnosed as leprosy patients, while millions
suffer from the sequelae of the disease. Hence in 1991 the
World Health Assembly called for a global effort to eliminate
leprosy as a public health problem by the end of the second
millennium.
Epidemiology
Transmission
Though Mycobacterium leprae was one of the first
microorganisms directly associated with a specific disease,
large gaps still exist in our knowledge (WHO 1998a). This
applies not only to the pathology and immunology, but also to
crucial epidemiological aspects. Figure 1 presents a simplified
model of the transmission of M. leprae, indicating that
infection does not necessarily lead to any symptom or lesion
specific for the disease leprosy. In fact, it is assumed that M.
leprae is not very pathogenic and that most infections do not
result in symptoms. Early symptoms of leprosy can be self-
limiting and skin lesions can heal spontaneously (Fine 1982).
Individuals who suffer from the disease, particularly those
with multibacillary (MB) leprosy, are sources for spread of the

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Figure 1 Transmission cycle of Mycobacterium Leprae. Modified
after Van Beers et al. (1996).
infection. The most important port of entry and exit of M.
leprae is the respiratory system, particularly the nose; its
dissemination through skin lesions seems to be less important.
But what happens to those who are infected but do not develop
the disease? Do some of them become carriers? And if so, are
they an important source in the transmission of the M. leprae?
There is increasing evidence from nasal polymerase chain
reaction (PCR) studies of temporary carriage or even
subclinical infection (Van Beers et al. 1996; Cree & Smith
1998) and that infected persons may go through a transient
period of nasal excretion, indicating that the mycobacterium is
highly infective (Hatta et al. 1995). Patients household
contacts, neighbours, and social contacts have an increased
risk of contracting the disease (Van Beers et al. 1999). Whether
this is mainly the result of closer contacts to the index case,
similar genetic and immunological background, environmental
factors, or a combination of all these, has still to be resolved.
A crucial factor in the process from infection to disease is
the immune status of the host. Research and debate have
focused on whether and how infections with other
microorganisms may modify the immune response to M.
leprae. It has, for example, been suggested that a previous
infection with Mycobacterium tuberculosis may boost the
immune system, thereby diminishing the chances of developing
leprosy (Lietman et al. 1997). BCG vaccination provides
protection against leprosy, although studies have shown the
degree of protection to vary from 20% to 80% (Fine 1995).
BCG immunization may also be responsible for a shift in
immune response from multibacillary to paucibacillary (PB)
leprosy (Chaudhury et al. 1994; Van Beers et al. 1996).
The consequences of an infection with the Human
Immunodeficiency Virus (HIV) on the risk of developing
leprosy remain controversial (Van Beers et al. 1996). Some
studies have suggested an association between HIV infection
and leprosy (Borgdorff et al. 1993; Van den Broek et al. 1997),
while others did not find any association (Pnnighaus et al.
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1991; Frommel et al. 1994; Kawamua et al. 1994). Also, it is
uncertain whether HIV infection is modifying the expression
or course of M. leprae infection (Sampaio et al. 1995). In
Ethiopia no evidence was found to support an association
between HIV infection and a shift towards multibacillary
disease (Frommel et al. 1994), whereas the seroprevalence of
HIV was higher in MB patients than in PB patients in Uganda
and Tanzania (Borgdorff et al. 1993; Kawuma et al. 1994).
These conflicting results may be explained by confounding
factors (Van Beers et al. 1996). Globally, however, there is no
indication as yet that the HIV epidemic is leading to a
significant increase in the number of leprosy patients. The
impact of HIV on leprosy may be minimal because it simply
takes too much time for an infection of M. leprae to develop
symptoms (Van Beers et al. 1996).
Distribution and trends
Table 1 gives an overview of the registered prevalence in 1999
and case detection rate in 1998, as reported by WHO (1999).
At the beginning of 1999, more than 800 000 leprosy cases
were registered for treatment worldwide. In 1998 a similar
number of new cases was detected. The distribution, however,
is very uneven. About 75% of the registered patients live in
South-east Asia, particularly in India. In 1998, 32 countries
had a leprosy prevalence exceeding 1 case per 10 000
population. In absolute terms the global leprosy burden was
concentrated in 16 countries (Table 2), with India as the
absolute number one (WHO 1998b). These national figures,
however, conceal clustering within countries and significant
differences in prevalence between regions, districts and
communities.
Figure 2 indicates that the registered prevalence has
decreased dramatically over the last decade, but is currently
levelling off (WHO 1998b). Over the same period, however, the
case detection rate has been more or less constant for most of
Table 1 Leprosy cases detected and registered (WHO 1999)
Cases detected Registered cases
in 1998 in 1999
(rate per 10 000) (rate per 10 000)
Africa 851 530 (0.8) 868 457 (1.1)
Americas 847 218 (0.6) 886 029 (1,1)
South-East Asia 689 069 (4.7) 635 719 (4.3)
Eastern Mediterranean 885923 (0.1) 009748 (0.2)
Western-Pacific 810 617 (0.1) 819 487 (0.1)
Europe 804 492 (0.0) 04 4765 (0.0)
Total 804 449 (1.4) 820 205 (1.4)
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Table 2 Cases detected (1998) and registered

Cases Rate per Registered Rate per prevalence (as of 1st January 1998) in 16
detected 10 000 prevalence 10 000 leprosy endemic countries (WHO 1998c)

India 524 411 5.3 527 344 5.3

Brazil 543 933 2.6 572 953 4.3
Indonesia 515 337 0.7 529 225 1.4
Madagascar 511 555 7.1 511 005 6.8
Bangladesh 511 320 0.9 513 248 1.0
Myanmar 559086 1.8 513 581 2.7
Nepal 557446 3.2 512 540 5.3
Nigeria 557176 0.6 512 878 1.1
Guinea 556117 8.4 554805 6.6
Philippines 554942 0.7 558749 1.2
Ethiopia 554444 0.7 558104 1.4
Mozambique 554195 2.4 511 072 6.2
Democratic Republic of Congo 553781 0.8 554863 1.0
Sudan 552633 0.9 554065 1.3
Cambodia 552438 2.2 551921 1.7
Niger 552288 2.3 552738 2.7

the time, although there has been a steady increase since 1995.
Though some global trends can be identified, there are
significant differences between countries. While in some
countries case detection rates are more or less stable (India), in
others these rates decrease (China) or even increase
(Bangladesh) (Smith 1997).
Recently, a lively debate has emerged on the significance of
these trends (in registered prevalence and case detection rate)
for the epidemiology of leprosy in general and the
transmission of M. leprae in particular. The use of prevalence,
and particularly prevalence of patients registered for treatment
(registered prevalence), as the main indicator for the
epidemiology of leprosy, has several caveats (Box 1).
In principle, incidence is a better measure for monitoring of
trends in transmission. However, virtually no information on
incidence rates exists (Fine 1992; Smith 1997). Case detection
rates (CDR 5 all new cases annually registered in health
facilities) are substantially flawed in functioning as proxy
indicators for incidence rates. Firstly, not all cases detected are
in actual fact recent new cases. Some ostensibly new cases may

25 Figure 2 Leprosy trend in 32

Case Detection rate endemic countries combined.
Prevalence and case detection rate per 10 000

Prevalence rate
20

15

10

0
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

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Box 1 Prevalence as the indicator for the elimination of leprosy as a
public health problem some caveats
Prevalence is highly influenced by the duration of the
disease. Since in earlier years patients often underwent
lifelong treatment, the introduction of multidrug therapy
(MDT) has had a profound impact on the duration of the
disease, and thus on the registered prevalence.
Not the real prevalence is measured but only the registered
prevalence. Those who have leprosy, but have not reported
to a health facility are not included in these figures. In
addition, when MDT was introduced in leprosy
programmes, patients who had been labelled and registered
for a long time as leprosy patients were discharged,
including several misdiagnosed cases (Fine 1992).
Furthermore, defaulters are continuously being removed
from leprosy registers and, thus, not included in registered
prevalence rates.
The prevalence measured is the point-prevalence (taken at a
certain moment in time, e.g. 1st January) and not the
period-prevalence. Patients that are treated for leprosy but
who have a shorter treatment schedule than one year, may
not be included, e.g. PB-patients;
Different diagnostic criteria have been used over the years
for leprosy. Hence inconsistency in case definition and
diagnosis makes comparisons between different control
programmes and years cumbersome.
already have suffered from leprosy for several years, but for
various reasons (stigma, inaccessibility of health services,
opportunity costs) not visited a health facility. They constitute
the so-called hidden backlog of leprosy cases. Defaulting and
re-registering (shopping), as well as relapses may also inflate
the figures for new cases detected. Secondly, detection of new
cases depends on the method and intensity of case finding.
Active case finding is likely to increase the number of newly
detected cases, while a poorly performing programme may
identify only a small proportion of all new cases. Active case
finding may also overestimate incidence rates, since some new
cases are self-healing and should be included neither in
prevalence nor in incidence rates. Consequently, the currently
available information is inadequate to anticipate trends in
leprosy epidemiology and transmission. Worldwide
information on the most crucial indicator, incidence, is lacking
(Smith 1997), while trends in CDR may be distorted as a result
of confounding and bias (Meima et al. 1997).
Leprosy control
Leprosy control has three main strategic components
(Feenstra 1994): Early detection of patients, their adequate
treatment, and providing comprehensive care for the
prevention of disabilities and rehabilitation.
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Early detection of patients
Patient delay varies with the level of stigma prevailing in a
certain area. Although stigma may have been reduced in
many countries, it is still considerable in some communities
(Myint et al. 1992; Raju & Kopparty 1995; Croft & Croft
1998). Public education and the provision of effective
treatment with multidrug therapy (MDT) play an important
role in further reducing the stigma linked with the disease
(Jopling 1991). (Multidrug therapy (MDT) was introduced
for leprosy control as a response to increasing resistance to
monotherapy with dapsone. The regimen for PB patients
consists of dapsone and rifampicin for six months, while the
regimen for MB patients consists of dapsone, rifampicin and
clofazamin for 12 or 24 months. Patients collect a monthly
blister pack which contains their daily medication.)
Due to the lack of a single independent gold standard for
diagnosis, the diagnosis of leprosy is based mainly on clinical
symptoms. Laboratory techniques (AFB microscopy) were
introduced for a relatively short period of time, but are now
being abandoned in several areas where leprosy is still
endemic. However, there is a need for an easy-to-use
diagnostic test, particularly because leprosy is a relatively rare
disease in many countries, with specific knowledge mainly
concentrated at central level and much less at the periphery.
Recently developed immunological and molecular assays
cannot be used as diagnostic tests in routine control
programmes, because they do not discriminate clearly
between infection, contamination, and disease (Van Beers
1998). However, these tests may be useful for the diagnosis of
subclinical infections and the detection of sources of
transmission.
Adequate treatment
Treatment with MDT of all leprosy patients became the
official strategy of the WHO in 1982, when widespread
resistance to dapsone had to be confronted. Consequently,
research focused particularly on the relapse rate of these new
MDT regimens (Cree & Smith 1998). Different definitions
and indicators have been used to describe relapse (rates),
which has often hampered comparison between studies.
WHO has defined relapse as a patient who successfully
completes an adequate course of MDT, but subsequently
develops new signs and symptoms of the disease during the
surveillance period or thereafter. In general, the number of
leprosy relapses reported in control programmes has been
low (Becx-Bleumink 1992; Jesudasan et al. 1996a;
Dasananjali et al. 1997; Li et al. 1997) and well below the
relapse rates reported in, for instance, tuberculosis control
programmes.
The 7th WHO Expert Committee on Leprosy considered,
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based on the results of a multicentre double blind trial
(Grosset 1997; WHO 1997a) with 24 years of follow-up, that
the 24-month MDT regimen for MB-leprosy can be shortened
to 12 months. The Medico-Social Commission of the
International Federation of Anti-Leprosy Associations (ILEP)
supported the advice of the WHO Expert Committee, because
a shortened course would reduce costs for both programme
and patient, and would reduce the proportion of defaulters
(ILEP 1998). Fear has been expressed that the relapse rate for
those with a relatively high bacterial load may be unacceptably
high (Van Brakel et al. 1989; Waters 1998; Lynch 1999).
Nevertheless, most leprosy-endemic countries have
implemented a shortened 12-month MB-MDT regimen within
a year after the Committee met.
A relatively new development is the introduction of a single
dose of rifampicin 600 mg plus ofloxacin 400 mg and
minocycline 100 mg (ROM) as an acceptable and cost-effective
alternative regimen for the treatment of single-lesion PB
leprosy. A multicentre double blind trial concluded that ROM
is almost as effective as standard 6-month WHO PB-MDT in
the treatment of single lesion leprosy (Single Lesion Multi-
Centre Trial Group 1997). However, questions were raised on
the methodology of the study (Lockwood 1997). Furthermore,
the debate should be seen in light of the fact that 80% of all
single-lesion PB cases are self-healing (Ekambaram &
Sithambaram 1977).
These days, most control programmes report treatment
completion rates of 6090% for PB patients and 4080% for
MB patients (ILEP 1999). Reasons for nonadherence are
reported to be economic (costs of transport, opportunity costs
of monthly clinic visits), as well as social and psychological
(self-stigma, no improvement of disabilities, mobility).
Unfortunately, results from studies are often inconsistent and
the exact relationship between these factors and compliance
remains largely obscure (Vadher & Lalljee 1992).
Prevention of disabilities and rehabilitation
Leprosy patients suffering from disabilities, which may
develop before, during or after MDT, are often easily
recognizable by the characteristic deformities of their eyes,
hands and feet. Impairments and disabilities develop in
stages, often starting with nerve damage due to neuritis and
leprosy reactions and resulting in the loss of protective
sensation, as well as the loss of muscle strength and
autonomic functions. The International Classification of
Impairments, Disabilities and Handicaps gives the following
definitions (WHO 1980):
Impairment: any loss or abnormality of psychological,
physiological, or anatomical structure or function.
Disability: any restriction or lack of ability (resulting
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from impairment) to perform an activity in the matter of
within the range considered normal for a human being.
Handicap: A disadvantage resulting from impairment or
disability, that limits or prevents the fulfilment of a role
that is normal, depending on age, sex, social and
cultural factors for the individual.
However, the chain disease-impairment-disability-
handicap is not a chronological process. Impairment
resulting from leprosy always entails at the same time
physical, psychological and social consequences and thus
involves a disability and a handicap. It ranges from the
inability to play a normal role at home and in the community
and meeting normal social obligations to complete alienation
from society and destitution. Unfortunately, with few
exceptions, the link between impairment, disability and
handicap has rarely been studied in detail (Van Brakel 1997).
In many concepts describing the burden of disease, including
the DALY (Murray & Lopez 1994), the socio-economic
impact of leprosy in terms of handicap is, also for reasons of
international comparison, not included.
Since the consequences of leprosy are physical,
psychological and socio-economical, rehabilitation covering
these aspects should ideally be interrelated and integrated.
Physical rehabilitation is a prerequisite for successful socio-
economic functioning. Successful coping with impairments
and disabilities is an important determinant of motivation for
preventing their worsening. In practice, however, physical and
socio-economic rehabilitation interventions have often been
separated.
Leprosy control programmes tend to consider only
physical rehabilitation. In some countries socio-economic
rehabilitation is covered by the government through social
welfare, NGOs or community-based rehabilitation (CBR)
programmes, which address severely deformed and destitute
patients living at home or in leprosaria, and may include
vocational training, income-generating projects and charity.
Most CBR programmes are tailored to specific local needs
and consequently differ from country to country and even
among different areas of the same country (Deepak 1995).
Integrating all aspects of rehabilitation into CBR
programmes remains a major challenge. However, a CBR
programme cannot substitute all rehabilitation services,
particularly not those relating to identification of at-risk
patients and prevention of disabilities (Deepak 1995), which
require close collaboration between community rehabilitation
workers and medical staff.
Towards elimination of leprosy by the year 2000
In 1991 the World Health Assembly adopted a resolution to
eliminate leprosy as a public health problem by the year 2000
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(WHO 1991). Elimination was defined as a level of prevalence
below one case per 10 000. Along with this resolution, WHO
advocated an approach consisting of four elements: Making
MDT available at community level, Leprosy Elimination
Campaigns (LECs), Special Action Projects, and close
monitoring of the impact, particularly through assessing the
prevalence of leprosy.
The approach has been successful in achieving almost
100% MDT coverage. In many countries LECs have resulted
in the detection of a considerable number of cases. Important
elements of the campaigns are training of health workers in
case finding, educating communities to increase awareness,
active case finding and treating patients. In Nepal more than
11 000 new cases were identified during last years national
campaign (Ministry of Health and Nepal Department of
Health Services 1998), while the number of new cases in the
previous year was around 7500 (Ministry of Health Nepal
1998). In 1997 and 1998 LECs were held in 29 Indian States
and Union Territories. More than 500 000 health workers
were involved and 454 290 new cases were detected
(Directorate General of Health Services 1999).
Though LECs have indeed yielded a substantial number of
new cases and may have reduced the backlog of leprosy cases,
some questions have been raised about their cost-
effectiveness, long-term impact and particularly their
diagnostic accuracy. The high number of patients detected
during these campaigns may indeed indicate a backlog of
patients and an underestimation of the leprosy problem, but
also considerable overdiagnosis and thus diagnostic
inaccuracy (WHO 1998c). Another concern is case-holding of
patients found through active case finding. Compared to
patients who report to health services voluntarily, these
patients may be less motivated to complete treatment, and
some of them may have limited access to health facilities.
Special Action Projects for the Elimination of Leprosy
(SAPEL) are meant to bring MDT to remote areas where
routine activities are nonexistant or have proven impractical
(no health infrastructure, geographically difficult to access,
refugees, etc.). SAPELs have generally been less successful:
they resulted in only a limited number of new cases (WHO
1996; Ebenso 1999), have been relatively expensive and had
questionable adherence levels.
While millions of patients have been released from MDT
and the global registered prevalence has decreased
substantially, it is likely that in several leprosy-endemic
countries the elimination target will not be reached.
Prevalence rates vary widely within countries and, as a result
various regions continue to have relatively high rates.
Nevertheless, the enhanced commitment for the
elimination target by the year 2000, to be reached by the main
tool for elimination, MDT, has given a strong impetus to
leprosy control (Feenstra 1992). The underlying assumption is
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that MDT, by making highly infectious patients rapidly
noninfectious, will have an impact on the transmission of M.
leprae. This assumption, however, has been challenged (Fine
1992). The degree of its impact, particularly on the incidence
of leprosy, is still largely unknown and subject of intensive
discussion (WHO 1998d). Reduced prevalence has mainly
resulted from shorter treatment schedules and clearing of
registers, not by a decrease in incidence. Nevertheless, WHO
is using registered prevalence as the main indicator to
monitor progress because of the operational difficulties in
measuring incidence.
The postponement of the elimination date to 2005, and the
suggestion by WHO that the next five years are necessary to
cure the remaining patients and that only a limited number
of leprosy patients may occur after the year 2005 (as stated
in the ILEP/WHO draft Strategic Plan 20002005 and the
Memorandum of Understanding between WHO and
Novartis Pharma AG), strengthen the idea that the leprosy
problem is on the point of disappearance (Li et al. 1997).
Such an approach is likely to be counterproductive, because it
may have negative consequences for future support, the
funding of research and the implementation of leprosy
control activities (Anonymous 1997). Presently, there is no
basis for confidence that the incidence and the number of
new leprosy patients detected annually will have been
substantially reduced in all currently endemic areas after the
year 2005, let alone be zero. Hence, leprosy control activities
should not be exclusively directed towards a magic target but
towards sustainable leprosy control, far into the new
millennium. This requires new strategies, rather than
questionable assumptions.
New directions for leprosy control
The introduction of new and relatively short MDT treatment
schedules, the expected reduction in priority given to leprosy
control, as well as ongoing health sector reforms, make it
imperative for national decision-makers to review the policies
and strategies for leprosy control. While leprosy-specific field
staff was often overburdened 20 years ago, when many
patients were on lifelong treatment, they now have to deal
with substantially lower patient loads.
However, if the impression is given that the leprosy
problem has been eliminated, political interest will wane,
certainly while other diseases such as AIDS, malaria,
tuberculosis and noncommunicable diseases require
increasing attention. (The use of the term elimination as a
public health problem is often confused with the definition
of elimination as was for instance defined during the
Conference on Global Disease Elimination and Eradication
as Public Health Strategies, in Atlanta, USA 1998 (Dowdle &
Hopkins 1998). Elimination was here defined as a reduction
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to zero of the incidence of a specified disease in a defined
geographical area as a result of deliberate efforts (Dowdle
1998). Control was defined as the reduction of disease
incidence, morbidity or mortality to a locally acceptable level
as result of deliberate efforts; continued measures are
required to maintain the reduction.) Though understandable,
reduced priority for leprosy should not lead to giving no
priority at all. Many examples in the past, e.g. in the case of
tuberculosis and malaria, demonstrate that abandoning
disease control programmes altogether has serious
repercussions when such diseases re-emerge.
The context in which disease control programmes are
operating is also changing (Green & Jochem 1998). Most
ministries of health are engaged in reforms, whether slow and
incremental or fast and radical. If a disease control
programme takes a passive and defensive attitude towards
these changes and their possible adverse effects, it might well
end up losing an opportunity to influence new health sector
policies.
To maintain political commitment is crucial. In this
context, promotion of (ex)patient organizations, capable of
pressurizing governments to fulfil their responsibilities, could
be an important activity. In Brazil, for instance, organizations
of patients, ex-patients and committed individuals have
gained strength in the past few years. These organizations
assist regular health services in health education, case finding
and case holding activities and confront failing leprosy
services with their poor performance.
It is essential that the process to change involves all
concerned parties from the start (governments, health
workers, patients, non governmental organizations, donors,
etc.). Workshops involving all stakeholders should develop
guidelines that can serve as a tool for managers and decision-
makers who want to review the organization of leprosy
services and to devise a strategy that will make them more
sustainable (De Coster et al. 1997). A well-defined strategy
aimed at efficient, effective and sustainable leprosy control,
presented at the right time, is crucial to keeping leprosy on
the agenda. Major components of this strategy are
summarized in Box 2.
Continuation of early case-finding, treatment with MDT and
prevention of disabilities
A high coverage of BCG-vaccination, early detection of
leprosy patients, followed by treatment with MDT and the
prevention of disabilities, will continue to be the cornerstone
of leprosy control in the 21st century. Passive case finding will
remain the most suitable method for early case finding.
However, in specific highly endemic areas, where awareness,
patient motivation, and diagnostic procedures are regarded as
inadequate, active case finding may be pursued.
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Box 2 Major components of a strategy for sustainable leprosy
control
Continuation of early case-finding, treatment with MDT
and prevention of disabilities
Enhancing cost-effectiveness, sustainability and equity of
leprosy services through integration and combination with
other disease control programmes
Development of tailor-made leprosy control strategies,
related to patient load
Strengthening human resource development and
management
Strengthening national level
Strengthening services for patients in need of medical and
social rehabilitation
Stimulating relevant research
Enhancing cost-effectiveness, sustainability and equity of
leprosy services through integration and combination with
other disease control programmes
As a result of decreasing prevalence (and therefore workload)
combined with high costs and health sector reforms, many
vertical programmes that still exist (e.g. India) will be
discontinued in the coming years. Instead, in order to be more
efficient and cost-effective and enhance accessibility, leprosy
programmes of the 21st century have to be merged with other
programmes and, preferably, integrated into the general health
services. Two components can be distinguished that are
mutually reinforcing:
Integration at the level where services are provided: This
implies that patients should be diagnosed and treated every day
of the week, close to their homes, by most, if not all, health
workers. Multipurpose clinics and staff should attend to the
curative and preventive needs of leprosy patients. This will
enhance the accessibility of leprosy services for all patients and
broaden their possibilities to complete treatment. It will ensure
that leprosy services continue in the decades to come (Feenstra
1993).
Integration needs to be supported by a well-organized health
system, particularly through technical support from higher
levels with training, supervision, drugs supply, monitoring and
policy development. The local context will determine the most
feasible modality to ensure that leprosy services remain of
good quality. Particularly the combination of leprosy activities
with tuberculosis has shown to be a promising option. Both
disease control programmes target chronic diseases and are
often traditionally linked; they are based on a public health
perspective with similar principles, i.e. aimed at decreasing
transmission by early case finding, adequate case-holding and
monitoring. In countries where a model for leprosy control is
well-developed, it can be used to enhance or expand
tuberculosis control. In some regions of Nepal, where the
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J. Visschedijk et al. Mycobacterium leprae millennium resistant!

leprosy control programme is supporting tuberculosis control,
the sustainability of leprosy control is enhanced because it
makes leprosy activities more cost-effective. Such an approach
offers good opportunities for countries such as Nigeria, where
leprosy control is relatively well-established but tuberculosis
control still relatively weak. Currently, combination with
tuberculosis control takes place in Tanzania, Nigeria,
Mozambique, Kenya, Ethiopia, and more recently in
Indonesia. In other countries leprosy services are combined
with dermatological services, e.g. in Vietnam, Laos, China,
Brazil and Surinam. In some settings it may be possible to hand
over all supportive activities to the general health services,
provided, of course, that sufficient attention is given to the
needs of the leprosy control programme and that the general
health services are of acceptable quality.
In several countries, integration at the level of service
delivery and the combination of technical support to leprosy
and tuberculosis control go hand in hand. In Ethiopia leprosy
services are currently integrated in the general health services
at the most peripheral level, while at the same time support to
this level is strengthened through the combination with
tuberculosis control. The number of clinics with facilities to
diagnose and treat leprosy has increased considerably and the
combined training and supervision for leprosy and tuberculosis
control increase the cost-effectiveness, and therefore the
sustainability, of these services.
Developing tailormade leprosy control strategies
Cost-effectiveness and sustainability can also be enhanced by
establishing tailormade leprosy control strategies. An
approach needs to be developed that links leprosy control
activities to the epidemiological situation in a country, e.g.
through the use of simple Geographical Information Systems
(GIS). Based on case detection rates, regions could be
categorized as follows:
approach is rather expensive. Under such circumstances a
cluster approach would be more appropriate. Services,
including the training of health workers, are mainly provided
in the area where the leprosy problem still exists. In Kenya,
for example, most new patients come from a limited number
of districts, which has consequences for the organization of
leprosy services.
In low-endemicity situations an outbreak approach is
needed, whereby contacts of the index case are examined.
Procedures should include the verification of diagnosis and
treatment of the index case and the examination of intensive
contacts. The community should be informed, and the health
staff in the area should be trained in diagnostic skills and
case management. Routinely, the skills of health workers will
mainly be limited to suspecting leprosy.
Strengthening human resource development and
management
A critical review of essentially required skills at all levels is
important for working towards sustainable services. Since
multipurpose workers are desirable, required leprosy-related
skills need to be carefully defined and standardized, while
excluding nonessential skills. Taking the recent WHO
initiative on the Integrated Management of Childhood Illness
(Lambrecht et al. 1999; Tulloch 1999) as an example, it may
be useful to consider an equivalent approach for
dermatological problems: the integrated management of skin
diseases. Simple and valid algorithms on the diagnosis and
management of skin lesions could help the peripheral health

Regions with high case detection rates (. 10 per 100 000

per year);
Regions with moderate case detection rates (110 per
100 000 per year);
Regions with low case detection rates (, 1 per 100 000
per year).
Traditionally leprosy control has followed a blanket
approach, whereby support was provided to all areas and to
all health service levels, irrespective of the number of
patients. This is still justified where the number of patients is
high and/or more or less evenly geographically distributed.
Ideally, all components of leprosy control should under these
circumstances be integrated into the basic health services, and
staff has to be trained in these components. Figure 3 Ranking of required skills in order of possibilities to
In situations with moderate case detection rates a blanket delegate to peripheral health services.

2000 Blackwell Science Ltd 395

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J. Visschedijk et al. Mycobacterium leprae millennium resistant!
worker to come to meaningful decisions and actions,
including those for leprosy.
A tailormade leprosy control strategy, depending on the
patient load, will have substantial consequences for the
specific level of expertise required. For most endemic settings,
the ability to suspect leprosy and refer (S & R) to a health
unit capable of diagnosing and providing treatment is the
most important skill required for peripheral multipurpose
health workers. The supervised provision of treatment is
another task that can be delegated to the lowest level. In areas
with low patient loads, management of nerve damage will
have to be concentrated in health facilities with a larger
catchment population, e.g. a district hospital serving
200 000500 000. The centres for the treatment of
complications of leprosy and rehabilitative surgical services
will be even more concentrated. As the number of contacts
between health workers and leprosy patients diminishes,
fewer staff will obtain skills in case management and leprosy
control. Figure 3 illustrates a hierarchical list of the required
skills.
To maintain minimum awareness of leprosy, leprosy must
be kept in the curricula of (para) medical workers, even under
low endemic circumstances. Each leprosy-endemic country
should have at least one centre of excellence for complicated
dermatological and surgical patient management. This need
not be a special leprosy hospital, but may well be an
adequately equipped general hospital.
Strengthening services at the national level
Regardless of the level of endemicity in a country, a well-
functioning central unit, usually in the Ministry of Health
(MoH), is necessary. The central unit should be responsible
for policy formulation and technical guidance, technical
training, and planning, monitoring, evaluation. MoH will
need to sustain an international technical exchange of ideas
and experiences. These contacts are of great importance to
maintain a sense of cohesion and to facilitate innovation.
Most endemic countries will want to maintain links with the
national and international donor community.
MoH should be capable of formulating a long-term health
policy embedding disease control policies including leprosy.
This requires, however, that the national disease control units
are equipped with strong skills in policy development,
communication and negotiation.
Strengthening services for patients in need of medical and
social rehabilitation
Worldwide, the number of ex-patients with deformities and
disabilities has already surpassed the number of patients in
need of MDT. Many of these people will need medical care
396
volume 5 no 6 pp 388399 june 2000
in the form of septic or reconstructive surgery. They should
have access to general surgical facilities. Due to stigma, this is
still not the case in several countries.
Grouping rehabilitative interventions into packages for
specific conditions or groups of disabled persons will
facilitate the decision-making and referral process, allowing
individual programmes to adjust the contents of the packages
according to their specific requirements. It allows for
transparency in terms of who is responsible for the delivery of
care. Budgets and costs could be related to the number of
registered disabled patients more easily. We propose the
following packages of interventions
Neuritis package: early diagnosis and treatment of
reactions and neuritis;
Self-care package consisting of health education,
provision of protective materials such as footwear,
bandages, sunglasses, etc.;
Surgical care package comprising hospitalized ulcer care,
septic surgery, reconstructive surgery and orthopaedic
footwear;
End stage or amputee package including health
education and the provision of prostheses and crutches.
The level at which these packages would be provided
depends on factors such as the case detection rate. Socio-
economic rehabilitation (SER) of leprosy patients will remain
an important issue. Severely deformed and destitute patients
may continue to live in special places such as leprosaria,
though admission to these places should, in general, be
discouraged. Community-based rehabilitation, where these
patients receive the same kind of services as other people
with severe disabilities, is preferable.
Stimulating relevant research
The fact that registered prevalence is low does not mean that
research is no longer needed (ILEP 1996). Health system
research in particular, formulated within the context of
specific leprosy control programmes and orientated towards
direct action, should be supported. In addition, three areas
for further research should be prioritized:
Studies to determine factors influencing the transmission
and to understand the impact of interventions on the
epidemiology of leprosy. This will also make
mathematical models to assess future trends in the
epidemiology of leprosy more relevant and reliable.
Research to elucidate the factors that cause delay in early
detection and influence health-seeking behaviour. Since
stigma, health infrastructure, etc., are often context-
specific, this is an area where health systems research can
enhance knowledge and develop relevant interventions.
2000 Blackwell Science Ltd
Tropical Medicine and International Health
J. Visschedijk et al. Mycobacterium leprae millennium resistant!
Research into early diagnosis and shortened treatment
schedules should be encouraged, in order to reduce
defaulter rates and (opportunity) costs.
Research on leprosy reactions and recent nerve damage
focusing on the development of tools for diagnosis and
the treatment of such reactions under field conditions,
e.g. standardization of the use of corticosteriods.
Conclusion
There are still substantial gaps in our knowledge of leprosy
transmission and epidemiology. Only when, through further
research, these gaps are closed, long-term strategies for real
elimination can be established. Currently, however, the
changing circumstances, such as a decreasing registered
prevalence, health sector reforms, a diminished commitment
and scarcity of resources, require a fresh look at policies and
strategies for leprosy control. Such a revision requires an
active position by decision-makers, because attempting to
carry on as usual is doomed to lead to the evaporation of
leprosy control.
We have provided directions for leprosy control in the
coming years, which partly build on experiences of the past
and partly require the development of new approaches.
Obviously, on the threshold of the new millennium, an
important chapter in the history of leprosy control will be
closed. However, it would be far too early to close the whole
book.
Acknowledgements
The authors thank Lex Muller for his intellectual and
technical support, Piet Feenstra for his useful comments and
Leonie McCann for her assistance in editing an earlier draft.
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