World Health Organization

Leprosy 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: daumeried@who.int

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

© World Health Organization,2004

This 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

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

5
 WHO Leprosy Elimination Project: Status Report 2003

Abbreviations used in the Text

AFRO WHO Regional Office for Africa
AMRO WHO Regional Office for the Americas
AMDT Accompanied MultiDrug Therapy
BBC/WST BBC World Service Trust
CBR Community-based rehabilitation
DANLEP Danish Assisted National Leprosy Eradication Programme (India)
EMRO WHO Regional Office for the Eastern Mediterranean
EURO WHO Regional Office for Europe
GIS Geographical Information Systems
GAEL Global Alliance for the Elimination of Leprosy
IAS Indian Administrative Services
IEC Information, Education and Communication
ILEP International Federation of Anti-Leprosy Associations
LCU Leprosy Control Unit (India)
LEC Leprosy Elimination Campaigns
LEM Leprosy Elimination Monitoring
MB Multibacillary leprosy
MDT Multidrug Therapy (Clofazimine, Dapsone, Rifampicin)
MLEC Modified Leprosy Elimination Campaign (India)
NGO Non-governmental Organization
NLEP National Leprosy Eradication Programme (India)
PAHO Pan American Health Organization
PB Paucibacillary leprosy
PHC Primary Health Care
POD Prevention of disabilities
SAPEL Special Action Projects for the Elimination of Leprosy
SEARO WHO Regional Office for South-East Asia
SSL Single skin Lesion PB leprosy
TAG Technical Advisory Group
TDR Special Programme for Research and Training in Tropical Diseases
UNDP United Nations Development Programme
WHO World Health Organization
WPRO WHO Regional Office for the Western Pacific

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.

6
 WHO Leprosy Elimination Project: Status Report 2003
Introduction
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-
7
Status of Elimination in 2003
• By the end of 2003, more than 13 million
cases had been cured.
• Among newly detected cases reported
with classifications in 2002, about 13%
were children (below the age of 15), 39%
were MB based on the clinical classifica-
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-
ing those which are difficult to access or
contain 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.
1. Announced at the 54th World Health Assembly in Geneva in
May 2001. The elimination of leprosy as a public health problem
is defined as the reduction of the leprosy prevalence at a given
point in time to a level below one case per 10,000 population,
at the national level. This definition of the elimination of leprosy
is used throughout this report.
 WHO Leprosy Elimination Project: Status Report 2003

The global leprosy situation

Greatly improved information systems now Table 2: Top endemic countries at the start of 2003
established in most endemic countries illustrate
the substantial progress made so far in eliminat- Region Registered cases at Cases detected
end of 2002 (rate during 2002
ing leprosy as a public health problem, using MDT per 10 000) (rate per 100 000)
to tackle the disease. The number of cases regis-
India 344 377 (3.3) 473 658 (46.0)
tered has been reduced by almost 90% since 1985,
Brazil 71 139 (4.1) 38 365 (22.3)
when MDT started being introduced into countries
Madagascar 6 602 (4.0) 5 482 (33.4)
on a global scale - from around 5.4 million to less
than 0.53 million at the beginning of 2003. Table 1 Mozambique 7 136 (3.6) 5 830 (29.1)

below shows the latest information on prevalence Nepal 7 291 (3.0) 13 830 (56.5)

and detection of leprosy by WHO region at the Tanzania 7 063 (2.1) 6 497 (19.0)
beginning of 2003. Total: 443 608 (3.4) 543 662 (41.9)

Table 1: Leprosy Situation as reported by 110 Table 3: Number of new cases detected during 2001
countries, at the beginning of 2003, by WHO region and 2002 by WHO Region (latest available data)

Region Registered Cases detected Region Cases detected during the year
Prevalence at during the year
end of 2002 2002 2001 2002
Africa 53 888 48 248
Africa 39 612 48 248
Americas 75 686 39 939
Americas 42 830 39 939
Eastern Mediterranean 7 899 4 665
Eastern Mediterranean 4 758 4 665
South East Asia 385 458 520 632
South East Asia 668 658 520 632
Western Pacific 11 335 7 154
Western Pacific 7 404 7 154
Europe 45 34
Europe 25 34
Total: 524 311 620 672
Total: 763 287 620 672
Note: Europe data shown for 2001 is 2000 data.
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 Republic, Congo, India, Liberia, Madagascar,
110 countries reporting). WHO attributes this to a Mozambique, Nepal and United Republic of
number of factors, such as the intensified efforts of Tanzania.
case detection, high transmission of the disease in
certain areas, over-diagnosis or re-registration of Table 2 shows the prevalence at the beginning
previously treated cases, targets set for case detec- of 2003 and detection during 2002 for the six top
tion in some programmes, and leprosy elimination endemic countries, according to the latest avail-
campaigns (about 50% of the cases are attributed able information. Together, these countries repre-
to the wide scale introduction of the LECs). sent 85% of registered cases and 88% of the new
cases detected in 2002.
At the end of 2003, 10 countries have not been
able to reach the elimination target at the national The latest available information shows that
level, and taken together, these countries still rep- 620,672 new cases were detected during 2002, a
resent the major part of the global burden of the 18.7% decrease compared with 2001 when 763,287
disease. These are: Angola, Brazil, Central African 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
Western Pacific 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

8
 WHO Leprosy Elimination Project: Status Report 2003

Leprosy: registered prevalence rates, end 2002

Prevalence Rates at end of 2002

(per 10 000 population)

3 to 7.3
1 to 3
0 to 1
No data

Leprosy: new case detection rates, 2002

New Case Detection Rates

(per 100 000 population)
20 to 89.3
10 to 20
5 to 10
1 to 5
0 to 1 or no data

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
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

9
 WHO Leprosy Elimination Project: Status Report 2003

Table 5: Leprosy Situation in the Africa Region than January to December. During 2003, evalu-
(AFRO) at the end of 2002 (latest available figures) ation exercises were undertaken which included
Country Point Cases Prevalence Detection the updating of registers in endemic countries in
Prevalence detected rate per rate per
during the 10 000 100 000 Africa, and in India, Myanmar and Brazil.
year 2002

Algeria 0 0 - -
In India, a national LEM exercise and a vali-
Angola 5,249 4,272 3.9 32.1
dation exercise for newly diagnosed cases were
completed by the end of the year (see details in
Benin 294 392 0.5 6.3
Annex 1). Preliminary results indicate that a sig-
Botswana
nificant number of new cases are wrongly diag-
Burkina Faso
nosed, previously treated cases are re-registered,
Burundi
or cases are simply non-existent. This is the first
Cameroon 893 1,597 0.6 10.3 time that a systematic validation of new cases
Cape Verde 12 4 0.3 0.9 has been undertaken in India on such a large
Central African
750 388 2.0 10.5
scale. The methodology and the process of this
Republic
validation are essential for an accurate analysis
Chad 547 233 0.7 3.0
of detection trends.
Comoros 288 288 4.0 40.4

Congo 384 362 1.3 12.0 Though leprosy remains a public health prob-
Cote d’Ivoire 1,552 1,358 1.0 9.0 lem in 10 countries, the greater part of the global
D.R. Congo 4,859 5,037 0.9 9.5 burden is now focused on the top 6 endemic
Equatorial Guinea - - countries, namely: India, Brazil, Madagascar,
Eritrea 27 27 0.1 0.7 Mozambique, Nepal and Tanzania. The total
Ethiopia
number of cases registered in these six coun-
Gabon 44 17 0.4 1.4

Gambia 96 72 0.7 5.4

Table 6: Leprosy Situation in the Americas (AMRO) at
the end of 2002 (latest available figures)
Ghana 886 204 0.4 1.0
Country Point Cases Prevalence Detection
Guinea 902 1,234 1.2 16.3 Prevalence detected rate per rate per
during the 10 000 100 000
Guinea Bissau 101 68 0.8 5.5 year 2002
Kenya
Anguilla 0 0 - -
Lesotho 20 20 0.1 0.9
Antigua 0 0 - -
Liberia 685 560 2.1 16.8
Argentina 1,182 386 0.3 1.0
Madagascar 6,602 5,482 4.0 33.4
Barbados 0 0 - -
Malawi
Belize 0 0 - -
Mali 531 609 0.5 5.3
Bolivia
Mauritania
Brazil 71,139 38,365 4.1 22.3
Mauritius 2 2 0.0 0.2
Chile 2 1 0.0 0.0
Mayotte
Colombia 1,728 596 0.4 1.4
Mozambique 7,136 5,830 3.6 29.1
Costa Rica
Namibia
Cuba
Niger 1,026 1,207 0.9 10.9
Dominican
Nigeria 5,890 5,078 0.5 4.5 283 205 0.3 2.4
Republic
Reunion Ecuador
Rwanda 14 8 0.0 0.1 El Salvador
Sao Tome Grenada 0 1 - 1.1
Senegal 450 434 0.5 4.5 Guatemala
Seychelles 0 0 - - Guyana 74 38 0.9 4.4
Sierra Leone 449 751 0.9 15.1 Haiti
South Africa 13 52 - 0.9 Honduras 8 2 0.0 0.0
Swaziland 4 1 0.0 0.1 Jamaica 11 2 0.0 0.1
Tanzania 7,063 6,497 2.1 19.0 Mexico 1,191 309 0.1 0.3
Togo
Trinidad &
68 34 0.5 2.6
Uganda 714 668 0.3 3 Tobago

Zambia Uruguay

Zimbabwe Venezuela

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 WHO Leprosy Elimination Project: Status Report 2003

Table 7: Leprosy Situation in the Eastern Table 9: Leprosy Situation in the Western Pacific
Mediterranean Region (EMRO) at the end of 2002 Region (WPRO) at the end of 2002 (latest available
(latest available figures) figures)
Country Point Cases Prevalence Detection Country Point Cases Prevalence Detection
Prevalence detected rate per rate per 100 Prevalence detected rate per rate per
during the 10 000 000 during the 10 000 100 000
year 2002 year 2002

Afghanistan 222 19 0.1 0.1 American Samoa 6 0 0.8 -

Bahrain 36 6 0.6 1.0 Cambodia 588 740 0.5 6.5

Djibouti 27 2 0.4 0.3 China 3,623 1,646 0 0.1
Egypt 2,405 1,318 0.3 1.9 Federated States 79 108 6.5 89.3
of Micronesia
Iran 326 82 0.0 0.1

Iraq Fiji 2 4 0 0.5

Jordan 0 0 - - Hong Kong 39 6 0.1 0.1

Kuwait 0 12 - 0.6 Korea 543 22 0.1 0

Libya 8 7 0.0 0.1 Lao People’s 162 155 0.3 2.8

Dem. Rep.
Morocco 340 60 0.1 0.2
Malaysia 955 181 0.4 0.8
Oman 6 8 0.0 0.3
Marshall Islands 48 52 7.3 78.8
Pakistan 1,983 1,202 0.1 0.7
New Zealand 3 - 0.1
Qatar 7 7 0.1 1.1
Papua New 620 552 1.3 11.2
Saudi Arabia 28 39 0.0 0.2 Guinea

Somalia 447 151 0.4 1.4 Philippines 3,334 2,479 0.4 3.2

Sudan 1,639 1,361 0.5 4.5 Samoa 8 12 0.4 6.6

Syria 3 3 0.0 0.0 Singapore 25 4 0.1 0.1

Yemen 422 388 0.2 2.1 Solomon Islands 26 26 0.6 5.7

Tonga 0 0 - -

Vanuatu 8 6 0.4 3.1

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

Major endemic countries

Prevalence detected rate per rate per
during the 10 000 100 000
year 2002

Bangladesh 8,143 9,844 0.6 7.5

WHO, in conjunction with the national pro-
Bhutan 33 13 0.2 0.6
grammes, has undertaken a country-by-country
Timor Leste 249 281 2.8 31.3
reassessment of the prevailing situation in the
India 344,377 473,658 3.2 44.4
major endemic countries. This section of the
Indonesia 16,837 12,377 0.8 5.8 report provides short profiles of some of the major
Maldives 19 29 0.6 9.9 endemic countries
Myanmar 5,494 7,386 1.1 16.0

Nepal 7,980 13,830 3.3 56.5 Brazil

Sri Lanka 1,639 2,214
Thailand 1,905 1,000
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.
0.9 11.6
Overview of the programme
0.3 1.6
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

11
 WHO Leprosy Elimination Project: Status Report 2003

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 step was the inclusion of leprosy as part of the basic
Child malnutrition, weight for age (% < 5 yrs) .. .. ..
health package for primary health facilities with an
administrative resolution passed in 2001.
Child immunization, measles (% < 1 year) 99 99 99

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

However, the momentum of the task force has
Human Development Index (HDI) value * .. .. 0.777 been lost, as responsibility for tuberculosis has
Illiteracy total (% age 15 and above) 14.4 13.1 12.7 been added to the mandate of the task force and
Illiteracy female (% of age 15 and above) 14.7 13.2 12.8 the team was expanded.
GNI per capita, Atlas method (current US$)* 4,740 3,630 3,070
Brazil has the second highest number of regis-
GDP growth (annual %)* 3.3 4.4 1.5
tered patients in the world after India. Prevalence
Aid per capita (current US$)* 1.8 1.9 2
rates at the national level are over four times the
Source: World Bank, World Development Indicators database, April 2003 world elimination target. There has been a steady
and UNDP , Human Development Report 2003.
* See Glossary for definition of terms increase in new cases over the past twenty years
and since 1998, over 38 000 new cases have been
Leprosy Situation MB PB Total

Cases detected during 2002** 16,569 15,583 38,390 Leprosy elimination in Brazil
Child cases (<15 years) amongst new cases 2,545

Grade 2 disability amongst new cases 1,601

Key indicators
Cases registered for treatment at end of year 78,403

Source: Ministry of Health, 2003 • Second most endemic country in the

** Individual MB and PB data incomplete for some states
world
• Prevalence and prevalence rate:
treat leprosy. This was clearly a major obstacle to 78,403 (4.2 / 10 000 population)
the elimination of leprosy. In November 1998 the • New cases and detection rate:
National Council of Municipal Health Secretaries 38,390 (22.3 / 100 000 population)
(CONASEMS) adopted a resolution to provide • Geographic focus: impoverished states
leprosy diagnosis and treatment at every health of North /Northeast
facility. The framework for this new partnership was Highlights of activities 2003
provided by a tripartite agreement between the Min- • National campaign (BBC, PAHO/WHO,
istry of Health, CONASEMS, and the Pan-American Health Ministry, MORHAN) to encour-
Health Organization (PAHO)/WHO. age early help seeking behavior
• Improved awareness of the signs of
A task force representing all key players leprosy
(the National Leprosy Programme of the Minis- Constraints to eliminating leprosy
try of Health, the municipal health secretaries • Limited access to leprosy diagnosis and
(CONASEMS), PAHO/WHO, MORHAN (a social treatment in endemic areas
mobilization organization for leprosy) and leprosy • Non adherence to fixed duration treat-
experts) was created in January 1999 to guide ment
the decentralization process. The Task Force also • Very centralized programme
oversaw the production and distribution of informa- Remedial actions needed
tion and training kits for use in the municipalities, • Accelerate decentralization of leprosy
funded jointly by the Ministry of Health, WHO and services in the endemic areas
the Novartis Foundation. Efforts focused on the • Urgent need to increase geographical
priority municipalities in the states of Bahia, Piaui, coverage of MDT
Tocantins, Pernambuco, and Rio de Janeiro. Sig- • Simplify information system
nificant progress was made to that end. A major (SINAN)

12
 WHO Leprosy Elimination Project: Status Report 2003
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 constraints
The 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 2003
WHO 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,
13
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.
India
Overview 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-
 WHO Leprosy Elimination Project: Status Report 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 trends
The 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
India
Development Indicators 1997
Population, total (millions) 965.4
Population growth (annual %) 1.7
National poverty rate (% of population) ..
Life expectancy at birth (years) 62.2
Fertility rate (births per woman) 3.3
Infant mortality rate (per 1,000 live births) 71
Under 5 mortality rate (per 1,000 children) ..
Child malnutrition, weight for age (% < 5 yrs) ..
Child immunization, measles (% < 1 year) 55
Access to affordable essential drugs %* ..
Human Development Index (HDI) value * ..
Illiteracy total (% age 15 and above) 45.1
Illiteracy female (% of age 15 and above) 57.5
GNI per capita, Atlas method (current US$)* 420
GDP growth (annual %)* 4.4
Aid per capita (current US$)* 1.7
Source: World Bank, World Development Indicators database, April 2003
and UNDP , Human Development Report 2003.
* See Glossary for definition of terms
Leprosy Situation MB PB
Cases detected during 2002 140,936 250,839
Child cases (<15 years) amongst new cases
Grade 2 disability amongst new cases
Cases registered for treatment at end of year
Source: Ministry of Health, 2003
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
2000 2001 high demands for MDT and - most worrying of all
1,000 1,000 - even cast doubts on the feasibility of the elimina-
1.6 1.5
tion strategy itself.
28.6 ..
There is some evidence to suggest that the
62.8 63
recent shift away from targets is already starting
3.1 3 to bear fruit in India, and this is reflected by the 23%
68 67 fall in new case detection in the twelve months up
95 93 to March 2003, This period includes a fourth round
.. ..
of leprosy elimination campaigns, when new case
detection would normally be expected to rise when
56 56
compared with non-campaign years.
.. 0-49
.. 0.59 The new data represents a significant fall in
42.8 42 detection even at the global level, as India rep-
54.6 53.6 resents close to 76% of the global burden of the
450 460
disease. Targets for new case detection have no
relevance once diagnosis and treatment are fully
4 5.4
integrated into the primary health care system, and
1.5 1.7
the decision by the Indian programme not to set
new case detection targets at the national level for
the year 2003 is highly significant.
Total
Although any such short term analysis of detec-
391,775
tion trends is fraught with potential problems, these
57,943
encouraging results may indicate that the backlog of
8,353
cases within the community is finally being cleared up,
322,898 more realistic estimates are now being made, and new
case detection rates will now continue to fall.
14
 WHO Leprosy Elimination Project: Status Report 2003

Table 10: India: Leprosy Situation 2002-2003

State or Union Registered New cases detection April 2002 - March 2003 Detection Registered Prevalence
Territory prevalence rate per prevalence rate per
at end of New MB New PB Total new MB % Female Child Grade 2 100 000 at end of 10 000
March 2002 cases cases cases % % disability % population March 2003 population

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 agency. From the preparation to the implementation

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
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.

15
 WHO Leprosy Elimination Project: Status Report 2003

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MDT supply management in India
India 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

16
 WHO Leprosy Elimination Project: Status Report 2003

Table 11: Epidemiological indicators, India

Year or

Andhra Pradesh

Uttar Pradesh
Chhattisgarh
Indicator

West Bengal
Maharashtra

Uttaranchal
Tamil Nadu
Jharkhand

Karnataka

Pradesh

Pradesh
Madhya

Orissa

Totals
Bihar
Prevalence trends in 12 priority states, 1998-2002 (rates per 10 000)
1998 5.5 11.7 7.9 7 2.3 9.2 4.9 23.9 7.1 4.1 2 4.8 3.6
1999 4.7 18.9 8.7 14.6 2.4 5.4 3.3 7.6 5.3 4.7 1.8 6.9 7.3
2000 5 18.7 8.5 14.6 2.6 5.8 3.7 11.2 5 6.1 2.1 5.3 8.8
2001 3.7 12.9 7.7 10.9 2.7 3 3.1 7 4.1 4.3 1.7 2.7 5.4
2002 3.2 10.9 10.8 12.9 2.4 2.3 3.3 8.9 3.5 5 2.2 4 5.3
New Case Detection trends in 12 priority states, 1998-2002 (rates per 10 000)
1997-1998 7.3 15.1 12.9 10.9 3.5 5.5 6.8 23.3 6.9 4 1 4.9 4
1998-1999 8.9 36.7 18.8 25 5.1 9.7 5.6 12.4 7.5 28.6 2.4 9.2 17.6
1999-2000 8 21.6 12.1 18 4.4 8 6.6 18 10.2 6.8 2.7 6.8 11.9
2000-2001 8.8 16.6 10.7 14.3 3.3 3.1 4.6 12.3 5.3 5.2 2.2 4.4 7.3
2001-2002 6.4 14 13.7 16.6 3.9 3 5 12.9 5.1 6.6 2.9 5.7 7.4
Case Finding Indicators in 12 priority states in 2002
% children 27 15.4 12.6 14.2 24.9 8 22.7 15.7 27.4 9.3 7.8 13.8 22.1
% MB cases 19.8 34.4 37.1 39.8 29.5 48.5 28.5 30.6 18.1 43.7 38.3 37.7 34.5
% of SSL PB 5.3 0.1 2.7 1 7 2.6 5.9 6.4 23.4 1 0.2 0.9 5.5
% Grade 2 1.4 2.2 3 2.4 0.8 5 1.6 1.7 1.4 1.9 2.3 2.6 2.9
Median delay 11.3 10.1 9.7 13 5.6 10.8 7.2 5.1 9.4 7.7 10.6 8 8.6
in diagnosis
% 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, 1998-2002
1997-1998 27.9 14.5 15.7 17.5 24.5 11.4 22.8 16.8 27 7.8 4.6 17 19.6
1998-1999 27.5 10.4 16 11.7 26 12.1 23.9 17 31.7 1.7 4.7 11.8 23.9
1999-2000 29.2 12.9 16 14.4 25.8 11.2 24.4 17.4 31.6 8.4 5.2 12.8 23.1
2000-2001 19.9 16 15.3 16.9 24.4 8.8 27.8 17.5 24.8 10.7 11.8 12.3 28.2
2001-2002 27 15.4 12.6 14.2 24.9 8 22.7 15.7 27.4 9.3 7.8 13.8 22.1
MB proportion among new cases trends in 12 priority states, 1998-2002
1997-1998 19.6 34.3 35.1 34.1 25.9 43.3 20.1 25 14.7 43.9 52.1 38.6 32.8
1998-1999 17.5 36.5 32.1 38.6 21.9 38.5 23.2 25.2 16.9 39.5 49.2 36.5 32.3
1999-2000 19.6 38.4 23.9 39.9 27.9 52.9 24.9 27.1 17.1 45.5 46.5 37.9 33.7
2000-2001 18.3 37.1 36 35.8 29.5 48.1 32.2 29.2 26 44.3 45.9 41.8 35.4
2001-2002 19.8 34.4 37.1 39.8 29.5 48.5 28.5 30.6 18.1 43.7 38.3 37.7 34.5
Disability grade-II proportion trends in 12 priority states, 1998-2002
1997-1998 2 4.3 4.6 5.2 1.4 7 1.3 2.1 2.5 5.3 16.9 4.7 4
1998-1999 1.6 4.5 3 4.8 0.8 5.5 1.6 2.1 2 1 4.3 4.1 6.2
1999-2000 1.8 3.2 3.3 3.4 1 4.7 1.6 1.9 1.4 2.9 4.3 3.3 3.7
2000-2001 1.4 2.2 3 2.3 1 5.5 2.1 1.8 1.8 2.4 2.6 3.1 2.5
2001-2002 1.4 2.2 3 2.4 0.8 5 1.6 1.7 1.4 1.9 2.3 2.6 2.9
Single Skin Lesion proportion trends in 12 priority states, 1998-2002
1997-1998 NA NA 13.7 NA 37.4 3.9 35.5 19.1 44.2 5.8 11.5 17.3 14.7
1998-1999 30.7 1.5 16.1 2.2 32.3 3.2 32.4 18.7 51.2 6.7 6 5.5 17.1
1999-2000 12.8 3.2 7.7 2 19.8 6 26.4 17.3 39.5 4.6 4.4 3.7 14.5
2000-2001 13.5 2.8 6.8 2.7 11.2 4.4 19.7 15.6 41.3 6.7 8.9 2.9 14.2
2001-2002 5.3 0.1 2.7 1 7 2.6 5.9 6.4 23.4 1 0.2 0.9 5.5
Female proportion trends in 12 priority states, 1998-2002
1997-1998 46 42.2 43.5 31.5 31.3 34.3 47.1 NA NA 23.9 NA NA NA
1998-1999 45 31.1 53.6 37.4 19.3 32.6 48.1 NA 39.9 37.2 NA NA NA
1999-2000 45.4 41.1 36.2 35 21.5 33.8 46.5 NA 38.5 42.8 NA NA NA
2000-2001 45 38.9 37.4 42.7 28.3 39.1 48.5 NA 44.3 35.9 NA NA NA
2001-2002 41.5 35.2 36.4 28.5 46.8 34.8 47.3 40.2 44.5 38.6 NA 31.8 NA

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.

17
 WHO Leprosy Elimination Project: Status Report 2003

Madagascar Leprosy Elimination in Madagascar

Overview of the programme Key indicators (2003)
Administratively, Madagascar is divided into 6 • Prevalence and prevalence rate:
federal provinces, which are subdivided into 28 6,602 ( 4.0 / 10 000 population)
regions, 111 sub-regions, 1 392 communes and • New cases and detection rate:
13 000 villages. There are currently 2 500 primary 5,482 (33.4 / 100 000 population)
health facilities in Madagascar giving a ratio of 1 • Geographic focus: entire country
health facility for every 5 000-7 000 inhabitants. except capital district
About 60% of the regions are difficult to access, Highlights of activities 2003
especially in the rainy season. • Updating of registers
• Development of plan to intensify lep-
The leprosy elimination programme is a semi- rosy elimination efforts
vertical programme. The director of the leprosy/ Constraints to eliminating leprosy
tuberculosis programme at the central level, is sup- • Poor geographical access to many
ported by leprosy-TB managers at the provincial health facilities especially in rainy
level. However at the district and peripheral level, season
leprosy is integrated into the general health serv- • National leprosy programme needs to
ices, although many primary health workers have be restructured
not been trained and are often not in a position to Remedial actions needed
diagnose and treat leprosy. • Strengthen and restructure leprosy
programme
The first serious effort to eliminate leprosy from • Make leprosy diagnosis and treatment
available at all health facilities
• Social mobilization in hyperendemic
areas
Madagascar
Development Indicators 1997 2000 2001 Madagascar was intiated in 1992 with training basic
Population, total (millions) 14.1 15.5 16 health staff and the introduction of MDT. LECs and
Population growth (annual %) 3.1 2.9 2.8 SAPELs were conducted in order to reach the many
National poverty rate (% of population) 73.3 .. ..
remote and high endemic areas in the country. In
2000 the groundwork to decentralize leprosy
Life expectancy at birth (years) 53.5 54.7 55.1
services was started but was derailed due to the
Fertility rate (births per woman) 5.8 5.4 5.3
political tensions in the country. In 2003 leprosy
Infant mortality rate (per 1,000 live births) 91.4 86 84 elimination efforts have regained momentum and
Under 5 mortality rate (per 1,000 children) .. 139 136 a national plan for the elimination of leprosy has
Child malnutrition, weight for age (% < 5 yrs) 40 .. .. been developed.
Child immunization, measles (% < 1 year) 46 55 55
Since 1992 there has been a steady increase in
Prevalence of HIV (female, % ages 15-24) .. .. 0.2
the number of new cases with a peak in the years
Access to affordable essential drugs %* .. .. 50-79
1997 and 1998 as a result of the LEC and SAPEL
Human Development Index (HDI) value * .. .. 0.468 campaigns. At the end of 2001 all the regions,
Illiteracy total (% age 15 and above) 36 33.5 32.7 except for Antananarivo had a prevalence rate
Illiteracy female (% of age 15 and above) 43.2 40.3 39.4 higher than 4 per 10 000 inhabitants. With the
GNI per capita, Atlas method (current US$)* 250 250 260
updating of the registers at the end of 2002 there
was a 64% drop in registered cases. In total 67
GDP growth (annual %)* 3.7 4.8 6
371 cases had been detected in the past decade
Aid per capita (current US$)* 58.9 20.8 22.2
with most cases detected in the second half of the
Source: World Bank, World Development Indicators database, April 2003
and UNDP , Human Development Report 2003.
decade.
* See Glossary for definition of terms
Key constraints
Leprosy Situation MB PB Total
Leprosy elimination efforts in Madagascar face
Cases detected during 2002 3,743 1,739 5,482
numerous problems including poor geographical
Child cases (<15 years) amongst new cases 823
access to many districts, particularly in the rainy
Grade 2 disability amongst new cases 437
seasons, fear of leprosy, lack of trainined health
Cases registered for treatment at end of year 6,602
staff and poor management of MDT supplies, inad-
Source: Ministry of Health, 2003
equate logistical support at the district level and

18
 WHO Leprosy Elimination Project: Status Report 2003

limited knowledge of the technical guidelines. Many

taboos and myths still surround leprosy which will
need serious efforts in developing IEC strategies Mozambique
for changing the negative image of leprosy in the
communities. Development Indicators 1997 2000 2001

Remedial actions needed Population, total (millions) 16.6 17.7 18.1

Population growth (annual %) 2 2.1 2

There is an urgent need to make leprosy
National poverty rate (% of population) 69.4 .. ..
services available at all health facilities (whether
Life expectancy at birth (years) 45.5 42.4 41.7
public or those run by religious organizations). This
will involve training of health staff, MDT supplies, Fertility rate (births per woman) 5.3 5.1 5.1

using WHO guides, coordination and supervision. Infant mortality rate (per 1,000 live births) 130.2 126 125

In addition a special effort must be made in the Under 5 mortality rate (per 1,000 children) .. 200 197
hyperendemic districts to update registers and Child malnutrition, weight for age (% < 5 yrs) 26.1 .. ..
conduct social mobilization programmes to detect
Child immunization, measles (% < 1 year) 70 97 92
hidden and new cases.
Access to affordable essential drugs %* .. .. 50-79

This will require restructuring the leprosy elimi- Human Development Index (HDI) value * .. .. 0.356

nation programme at the national and provincial Illiteracy total (% age 15 and above) 59.4 56 54.8

level to strengthen the support to the basic health Illiteracy female (% of age 15 and above) 74.7 71.3 70
centres. To train provincial teams to guide and GNI per capita, Atlas method (current US$)* 180 210 210
lead the activities in the periphery and thereby help
GDP growth (annual %)* 11.1 1.6 13.9
ensure the availability of leprosy diagnosis and MDT
Aid per capita (current US$)* 57 49.6 51.7
at all health facilities.

Mozambique
Source: World Bank, World Development Indicators database, April 2003
and UNDP , Human Development Report 2003.
* See Glossary for definition of terms

Overview of the programme Leprosy Situation MB PB Total

The health sector in Mozambique has suffered Cases detected during 2002 3,679 2,151 5,830

from the prolonged civil war, low levels of financ- Child cases (<15 years) amongst new cases 599

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.
Grade 2 disability amongst new cases 479
Cases registered for treatment at end of year 7,136
Source: Ministry of Health, 2003
centres, and the creation of Provincial Task Forces
in the five northern provinces.

Leprosy is highly endemic in Mozambique Constraints to eliminating leprosy

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
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 needed
In 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-

19
 WHO Leprosy Elimination Project: Status Report 2003

Leprosy elimination in Mozambique Nepal

Key indicators (2003)
• Prevalence and prevalence rate:
7,136 ( 3.6 / 10 000 population)
• New cases and detection rate:
5,830 (29.1 / 100 000 population)
• 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 programme
Remedial 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
Overview 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
Development Indicators 1997 2000 2001

mended as a means of encouraging patients to Population, total (millions) 21.4 23 23.6

report regularly for treatment. Information cam- Population growth (annual %) 2.4 2.3 2.3
paigns in the community should insist on the early National poverty rate (% of population) .. .. ..
signs of leprosy and the availability and free supply
Life expectancy at birth (years) 57.4 58.9 59.4
of leprosy drugs.
Fertility rate (births per woman) 4.5 4.3 4.2

As a first step leprosy services will be made Infant mortality rate (per 1,000 live births) 79.8 72 66

available in all 419 health facilities in the high Under 5 mortality rate (per 1,000 children) .. 95 91
endemic provinces of Nampula, Cabo Delgado, Child malnutrition, weight for age (% < 5 yrs) .. .. 48
Zambezia, Niassa and Manica. This will involve the Child immunization, measles (% < 1 year) 73 71 71
training of health staff as well as reorganizing the
Access to affordable essential drugs %* .. .. 0-49
supervision. In addition, social mobilization efforts
will be initiated in the 81 districts of these provinces Human Development Index (HDI) value * .. .. 0.499

to encourage people to seek diagnosis and treat- Illiteracy total (% age 15 and above) 61.7 58.3 57.1

ment. Another key activity will be the updating of Illiteracy female (% of age 15 and above) 79.2 76 74.8
the leprosy registers in the three most endemic GNI per capita, Atlas method (current US$)* 230 240 250
provinces. GDP growth (annual %)* 5.3 6.2 4.8

Aid per capita (current US$)* 18.7 16.9 16.5

In view of the poor coverage of health services,
alternative means to improve access to MDT have Source: World Bank, World Development Indicators database, April 2003
and UNDP , Human Development Report 2003.
been initiated in the past, including the creation of * See Glossary for definition of terms

MDT distribution points as well as involvement of Leprosy Situation MB PB Total

volunteers to suspect leprosy. The impact of these Cases detected during 2002 5,980 7,850 13,830
activities still needs to be assessed.
Child cases (<15 years) amongst new cases 961

Grade 2 disability amongst new cases 596

Import regulations made by the Mozambique
Cases registered for treatment at end of year 7,980
authorities in 1996 are still in place, which continue
Source: Ministry of Health, 2003
to cause lengthy delays in WHO shipments.

20
 WHO Leprosy Elimination Project: Status Report 2003

tional integration of leprosy control services into

Leprosy elimination in Nepal
Key indicators (2003)
• Prevalence and prevalence rate:
7,980 ( 3.3 / 10 000 population)
• New cases and detection rate:
13,830 (56.5 / 100 000 population)
• Geographic concentration: entire coun-
try except capital district
Highlights of activities 2002
• Updating of registers
• Development of plan to intensify lep-
rosy elimination efforts
Constraints to eliminating leprosy
• 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
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

and more involved in the development of plans of

Tanzania
action for leprosy elimination. Continued training
of health workers, together with strengthening Development Indicators 1997 2000 2001

supervision and monitoring by management train- Population, total (millions) 31.3 33.7 34.4

ing workshops for district health officers, introduc- Population growth (annual %) 2.6 2.2 2.1
tion of accompanied MDT services to improve cure National poverty rate (% of population) .. .. ..
rate, and intensified case finding activities such as
Life expectancy at birth (years) 47.9 44.4 43.7
focused LECs are the key strategies to intensify
Fertility rate (births per woman) 5.6 5.3 5.2
leprosy elimination activities.
Infant mortality rate (per 1,000 live births) 103.4 104 104
Remedial actions needed Under 5 mortality rate (per 1,000 children) .. 165 165

Accessibility is to be further improved by Child malnutrition, weight for age (% < 5 yrs) .. .. ..
strengthening the integration of MDT services up Child immunization, measles (% of < 1 year) 73 78 83
to the sub-health post level in all the Regions. IEC
Access to affordable essential drugs %* .. .. 50-79
materials and simplified guidelines for elimination
Human Development Index (HDI) value * .. .. 0.4
in local language will be provided to all health facili-
ties to improve the MDT services and community Illiteracy total (% age 15 and above) 28.5 25 24

awareness. In addition, mass media will be used Illiteracy female (% of age 15 and above) 38.1 33.5 32.1

to promote community awareness and to reduce GNI per capita, Atlas method (current US$)* 210 270 270
the stigma against those who have contracted the GDP growth (annual %)* 3.5 5.2 5.7
disease.
Aid per capita (current US$)* 30.2 30.3 35.8

Tanzania Source: World Bank, World Development Indicators database, April 2003
and UNDP , Human Development Report 2003.
* See Glossary for definition of terms
Overview of the programme
Leprosy Situation 2002 MB PB Total
The Tanzania National Tuberculosis and Lep-
Cases detected during 2002 3,747 2,750 6,497
rosy Programme (NTLP) was launched by the
Ministry of Health in July 1977. The Programme is Child cases (<15 years) amongst new cases 663

funded by the Tanzanian government and external Grade 2 disability amongst new cases 670

donors from both governmental and non-govern- Cases registered for treatment at end of year 7,063

mental organisations. There is structural and func- Source: Ministry of Health, 2003

21
 WHO Leprosy Elimination Project: Status Report 2003
Leprosy elimination in Tanzania
Key indicators (2003)
• Prevalence and prevalence rate:
7,063 ( 2.1 / 10 000 population)
• New cases and detection rate:
6,497 (19.0 / 100 000 population)
• Geographic focus: 13 out of 21
regions
Highlights of activities 2002
• LEM highlighted problems and updating
of registers
• Development of plan to intensify lep-
rosy elimination efforts
Constraints to eliminating leprosy
• 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
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-
22
cally difficult to access areas, refugee populations
and nomadic populations.
Key constraints
Despite 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 required
There 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.
 WHO Leprosy Elimination Project: Status Report 2003

MDT Drug Supply by WHO

MDT Drug Supply
Trends in MDT drug supply
Since 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
WHO MDT Supply: 1995-2003
10,000,000
9,000,000
8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000
2,000,000
1,000,000
0
1995 1996 1997 1998
• 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
WHO Representatives’ office;
• Standardising the reporting of registered
prevalence and MDT drug flow informa-
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 flow and
other essential indicators at sub-national
levels.
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
1999 2000 2001 2002 2003

M B Adult M B Child PB Adult PB Child 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
WHO MDT Supply (Adjusted): 1995-2003
reversed. The second chart therefore, despite the
10,000,000 many limitations outlined above, provides a more
realistic reflection of long term trends in MDT con-
9,000,000
8,000,000
7,000,000
6,000,000
sumption than the first chart.
5,000,000
4,000,000
3,000,000
MDT procurement and supply
2,000,000
1,000,000 Annual meetings are held with Novartis (usu-
ally in November) to finalise the projected require-
0
1995 1996 1997 1998 1999 2000 2001 2002 2003*

M B Adult M B Child PB Adult PB Child

* Adjusted to show postponem ent of 30% of 2002 India shipm ents to 2003.
ments for the following year’s supply of MDT. Such

23
 WHO Leprosy Elimination Project: Status Report 2003
Leprosy: MDT supply to countries 1995-2003
WHO Supply of MDT 1995-2003
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 design
The 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’
24
First Supplied 2003
Supplied 1995-2002
No supply
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 assurance
Although 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 levels
As 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 Leprosy Elimination Project: Status Report 2003
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 stock
From 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.
25
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
Special Campaigns for Elimination
In recent years, campaigns have been carried
out in areas presumed to have high caseloads of
leprosy or among population groups where services
 WHO Leprosy Elimination Project: Status Report 2003

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 community
awareness (self-reporting by patients) and
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
not only in a significant proportion being
wrongly 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.

Table 12. Detection during the Special Campaigns conducted during 2002

Area and country Population Detection during Special Campaigns 2002

covered
Total Detection MB (%) Grade 2 Child Female
Cases rates (per disability cases cases
detected 100 000) (%) (%) (%)
Ayeyarwaddy Division, Myanmar 6,626,076 955 14.41 44.9 17.8 8.5 NA

11 Districts (130 village 887,888 430 48.42 39.3

development committees), Nepal
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

26
 WHO Leprosy Elimination Project: Status Report 2003

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 Series
Total 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 57,817 36.8 3.9 41,106 43.5 3.6 31,203 38.8 1.5 15,307 34.6 3.2
State, India
Madhya Pradesh
and Chhatisgarh 20,248 31.8 6.1 17,176 37.7 5.1 14,970 33.6 2.6 4,929 35.6 2.3
States, India
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

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

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

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 using various communication methods

for diagnosis;
• starting treatment with the first dose of MDT
and 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,
specially adapted to local situations.
Achievements
Table 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

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

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

Bihar and Jharkhand States, India

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

Mandalay Division, Myanmar

1,443 1,288 1,585 2,330 5,099 2,301 2,552 1,055
(1998, 1999 & 2001)
Ayeyarwady Division, Myanmar
1,263 1,269 1,007 2,609 5,735 1,286 777 1,735
(1998, 1999 & 2002)
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

- 4,354 3,791 14,952 5,646 5,751 5,803 -
(1998 & 2001)

27
 WHO Leprosy Elimination Project: Status Report 2003

Table 14. India: Fourth MLEC

State or Union Territory New case detection by category Grade 2 New case detection by age & sex
disability
MB PB SSL* Adult Child
M F M F

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

Active Search

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

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
Voluntary Reporting System

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

Haryana

Punjab

Himachal Pradesh

Nagaland 7 13 1 0 17 4 0 0

Sikkim
Passive Detection

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

28
 WHO Leprosy Elimination Project: Status Report 2003
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
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-
2. MDT services include diagnosis, treatment with MDT, coun-
selling for patients and their families, community education and
referral for complications.
29
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.
Achievements
Reaching 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.
 WHO Leprosy Elimination Project: Status Report 2003

Table 16. Regional distribution of SAPELs

WHO Region Country (number of projects) Estimated No. of cases
population detected and
coverage treated (per 100
000 population)
Africa Central African Republic (1), Chad (2), Congo (1), Côte d’Ivoire (1), 2,058,585 3,030 (147.18)
Democratic Republic of the Congo (4), Madagascar (3), Mali (3),
Nigeria (2), Togo (1), United Republic of Tanzania (1)
Americas Bolivia (1), Brazil (10), Colombia (1), Paraguay (1), Venezuela (2) 1,317,690 770 (58.44)

Eastern Somalia (1), Sudan (12), Yemen (5) 1,300,080 2,561 (196.98)
Mediterranean
South East Asia Bangladesh (1), India (3), Indonesia (4), Myanmar (6), Nepal (3) 489,860 433 (88.39)
Western Pacific Cambodia (3), China (1), Papua New Guinea (4), Philippines (3), 2,795,890 657 (23.49)
Viet Nam (6)

Introducing innovative solutions
SAPELs 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 treatment
SAPELs 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

30
 WHO Leprosy Elimination Project: Status Report 2003

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 areas
A 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 participation
The 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).
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 activities
SAPELs 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.

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 patients
National authorities conducted a follow-up of
cases detected during SAPELs (Table 17). Because
of the difficulties in undertaking such an exercise,
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 No. of Cases Detected PBa MBb
follow-up Cure Cure
PB MB Total
Rate % Rate %
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

31
 WHO Leprosy Elimination Project: Status Report 2003
Cost-effectiveness
SAPEL 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 endemicity
In 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.
Conclusion
SAPELs 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.
32
UN Special Initiative
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
 WHO Leprosy Elimination Project: Status Report 2003
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.
Global Research
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 opportunities
The 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
33
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 damage
Although 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 integration
In 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.
 WHO Leprosy Elimination Project: Status Report 2003
TAG Meeting 2003
The 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,
by using flexible approaches that are both
innovative 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
34
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
are available for use in field programmes
within the next 5 years.
• TAG re-states its recommendation that
leprosy elimination campaigns (LECs) are
a useful approach to accelerate elimination
activities in specific endemic areas. 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 of Accompa-
nied-MDT3 would give better access to
MDT for patients in general and spe-
cifically for those who are unable to visit a
health 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
use under field conditions.
• 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 defined
period of time.
• TAG considers that validation or certification
of leprosy elimination at a point of time is a
very difficult and time-consuming exercise
that 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.
 WHO Leprosy Elimination Project: Status Report 2003
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.
Perspectives & Plan 2004
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-
35
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
 WHO Leprosy Elimination Project: Status Report 2003
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.
WHO activities in 2004
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.
• To prepare scientific papers, including chap-
ters for under-graduate and post-graduate
text books (e.g. Manson’s Tropical Medi-
cine).
• To attend scientific meetings.
• 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
36
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 and
integrated 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
multicentric study to assess the efficacy of
uniform multidrug therapy (U-MDT) for all
types of leprosy cases is being launched.
Five field sites have been identified in India
to 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
2006 and final results in 2009.
• WHO and TDR promote the use of genom-
ics in developing specific diagnostic tools
for leprosy under field conditions. WHO
has started advocating and mobilizing
 WHO Leprosy Elimination Project: Status Report 2003

resources for this purpose, in collabora- as follows:

tion with TDR and Pasteur Institute.
• Coordination of regional and country level
elimination plans and financial support for Elimination indicators
elimination activities to regions and coun-
tries. • Prevalence and detection rates found in the
LEM survey were close to those reported

Annex 1: LEM India by the annual reports with a few excep-

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
rate of leprosy (≥ & < 5/10,000). A sample of 20%
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
tions. However the reported prevalence
and detection rates were inflated in most
of 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
prevalence after applying standard defini-
tions was found approximately similar in
many states. However, in Bihar, Chhat-
tisgarh, Delhi, Maharashtra and Tamil
Nadu, the reported prevalence was found
significantly higher.
• 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

Leprosy Elimination Monitoring

Leprosy 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:

• Elimination indicators: Internal validity of information on prevalence and detection (crude and specific)
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.

37
 WHO Leprosy Elimination Project: Status Report 2003
Andhra Pradesh to 60% in West Bengal.
These figures were affected by the high
proportion 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
new cases, the LEM findings showed an
average 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.
38
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
even after completing fixed duration MDT.
• 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.
 WHO Leprosy Elimination Project: Status Report 2003
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
testing the skin sensory deficit and nerve
thickening.
2. Every newly detected case should be asked
39
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
India Guidelines on fixed duration MDT
treatment (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.
 WHO Leprosy Elimination Project: Status Report 2003

Annex 2: MDT supply 2003 and plans for 2004

MDT supply by country in 2003 Table 19: MDT Supply to countries in the American
Region (AMRO) in 2003
Table 11 that follows provides a regional sum- Country
WHO MB MB PB PB
Order Adult Child Adult Child
mary of MDT that was supplied to countries by WHO
Argentina 03/01833 2,880 0 864 0
in 2003. This table does not include the smaller
emergency shipments made from the WHO buffer Argentina 03/16369 5,760

stock held in Geneva, whcih are shown separately Bolivia 03/01248 816 96 96 48

in Table 17. Tables 12 to 16 show shipments Brasil 03/01850 236,160 15,552 152,064 15,552

grouped by individual country within the African Brasil 03/07955 108,288 24,768 50,112 23,328

Region (AFRO), the Americas (AMRO), East- Colombia 03/02180 2,880 0 1,728 0
ern Mediterranean (EMRO), South East Asian Colombia 03/12886 16,704 1,728
(SEARO) and Western Pacific (WPRO). Cuba 03/02198 1,728 0 864 0

Cuba 03/18558 3,360 96 672 192

Note that in some cases, countries received Dominican 03/01892 1,056 48 0 48
more than one order, whilst in others there were Republic

multiple, partial shipments within each order. Large Guyana 03/02058 288 96 96 96
orders (e.g. to India and Brazil) were split into sev- Haiti 03/01906 1,056 96 768 96
eral shipments over the whole year. Honduras 03/01329 288 48 48 48

Paraguay 03/01469 5,712 48

Table 18: MDT Supply to countries in the African
Venezuela 03/02147 2,304
Region (AFRO) in 2003
Totals: 389,280 40,800 209,088 39,408
WHO MB MB PB PB
Country
Order Adult Child Adult Child

Angola 03/16628 34,560 3,456 9,504 8,640 Table 20: MDT Supply to countries in the Eastern
Burkina Faso 03/01868 4,608 0 864 0 Mediterranean Region (EMRO) in 2003
Burundi 03/01256 2,880 0 0 0 WHO MB MB PB PB
Country
Order Adult Child Adult Child
Cameroon 03/01884 3,456 576 0 864
Afghanistan 03/01230 576 144 432 0
Central African 03/14722 4,608 144 240 144
Republic Egypt 03/01299 15,552 0 864 0

DR Congo 03/01272 16,128 2,880 11,232 0 Pakistan 03/18540 8,976 240 624 240

DR Congo 03/01922 21,888 0 4,320 0 Somalia 03/01493 1,728 240 96 96

Equatorial 03/02155 240 48 96 48 Sudan 03/01515 11,520 0 4,320 0

Guinea
Sudan (South) 03/02066 8,064 1,728 288 288
Ethiopia 03/15257 49,536 4,608 5,184 1,728 Yemen 03/01825 6,912 720 2,592 384
Gabon 03/02040 576 96 240 144 Totals: 53,328 3,072 9,216 1,008
Gambia 03/02201 576 96 240 96

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

Table 20: MDT Supply to countries in the South East
Guinee 03/01302 9,216 1,152 1,728 0 Asia Region (SEARO) in 2003
Kenya 03/01396 2,304 0 0 0 Country WHO MB MB PB PB
Order Adult Child Adult Child
Liberia 03/01400 3,456 576 864 0
Bangladesh 03/01841 30,528 0 9,504 4,320
Madagascar 03/02082 25,344 2,304 0 0
Bangladesh 03/10760 5,760
Malawi 03/02104 2,304 192 1,728 432
India - Madras 03/01337 44,928 120,096
Mali 03/01426 5,760 576 2,592 864
India - 03/01345 29,376 90,720
Mozambique 03/02171 2,880 0 0 0 Hyderabad
Mozambique 03/10484 58,752 2,304 12,096 2,592 India - Karnal 03/01353 50,112 123,552
Niger 03/02163 288 288 India - Calcutta 03/01361 44,928 123,552
Nigeria 03/01442 50,112 4,032 1,728 0 India - Bombay 03/01370 50,112 123,552
Senegal 03/01485 4,608 0 864 0 Indonesia 03/01388 126,720 8,640 8,640 0
Sierra Leone 03/02112 1,344 192 48 48 Indonesia 03/24558 60,480 9,792 19,008 2,592
Tanzania 03/01523 46,080 1,728 8,640 0 Nepal 03/01434 89,856 0 34,560 0
Togo 03/01531 3,072 96 0 0 Nepal 03/03666 4,608 6,048 6,048
Uganda 03/02139 2,832 48 0 0 Sri Lanka 03/01507 11,520 0 3,456 0
Zambia 03/01914 0 240 2,112 48 Sri Lanka 03/19643 10,368 4,032 10,368 6,912

Totals: 369,792 26,784 65,472 16,080 Totals: 336,960 255,168 91,584 601,344

40
 WHO Leprosy Elimination Project: Status Report 2003

Table 21: MDT Supply to countries in the Western Table 24: Use of Geneva buffer stock in 2003
Pacific Region (WPRO) in 2003 Country Port of Entry MB MB PB PB
WHO MB MB PB PB Adult Child Adult Child
Country
Order Adult Child Adult Child Argentina AMRO 1,152 864
Cambodia 03/01876 3,456 768 480 0 Afghanistan EMRO 1,728 192 480 96
Cambodia 03/18159 3,456 Guyana AMRO 672 96 96 96
China 03/01264 9,216 0 864 0 Comores AFRO 2,592 864
China 03/01264 9,792 0 0 0 Gambia AFRO 48 48
Malaysia 03/01418 4,608 0 864 0 Sierra Leone AFRO 240
Papua New 03/14749 576 576 1,728 864 Colombia AMRO 240
Guinea
Cambodia WPRO 576 480
Philippines 03/01477 22,464 2,880 864 0
Burundi AFRO 288 288
Philippines 03/01477 21,888
Dominica AMRO 48 48
Viet Nam 03/15940 7,488 576 2,592 864
South Sudan EMRO 576
Totals: 82,944 4,800 7,392 1,728
Bangladesh AMRO 576

Uganda AFRO 98 480 96

Table 22: Global Summary MDT Supply in 2003 Mozambique AFRO 576 864
Country MB MB PB PB
Adult Child Adult Child Paraguay AMRO 144

Africa (AFRO) 369,792 26,784 65,472 16,080 South Sudan AFRO 96 288 96 96

Americas (AMRO) 389,280 40,800 209,088 39,408 CAR AFRO 576 96 240 96

Eastern Mediterranean 53,328 3,072 9,216 1,008 PNG WPRO 0 96 864 192
(EMRO)
Vietnam WPRO 480 480
South East Asia (SEARO) 336,960 255,168 91,584 601,344
Cambodia WPRO 1,200 528
Western Pacific (WPRO) 82,944 4,800 7,392 1,728
DR Congo WPRO 1,008 96 768 96
Totals: 1,232,304 330,624 382,752 659,568
Cape Verde AFRO 288 48 48 48

Angola AFRO 8,640 2,592

Paraguay AMRO 1,728

Table 23: Supply of loose clofazimine in 2003
Burkina Faso AFRO 576 1,440 288
Country CLO 50mg CLO 100mg
Dominican AMRO 2,304
Republic
Bangladesh 5,000 10,000 Cape Verde AFRO 288 48 48 48
Pakistan 3,000 10,000 Sierra Leone AFRO 2,304 576 1,728 864

Viet Nam 1,000 6,000 Zambia AFRO 96 96

Sudan 2,000 Ecuador AMRO 96 192 96

Trinidad & Tobago 1,000 500 Swaziland AFRO 48 48 48 48

Guyana 1,000 4000 Chile AMRO 48 48 48 48

Eritrea AFRO 1,152 96 1,344 192

Viet Nam 5,000 20,000
CAR AFRO 5,184 576 2,352 240
Sudan 1,000 4,000
Mexico AMRO 4,032
Sri Lanka 2,000 19,000
Totals: 31,296 6,674 17,568 6,528
Malaysia 1,000 10,000
Lao PDR 1,000 10,000
Geneva Buffer receipts 41,472 10,032 18,144 10,368
St Lucia 500
Angola 5,000 20,000
Jamaica 1,000 1,000
Trinidad & Tobago 2,000 2,000 Table 25: Summary of planned MDT supplyin 2004 by
WHO Region.
New Zealand 1,000 500
Country MB MB PB Adult PB
Cambodia 20,000 Adult Child Child

Tanzania (pending) 2,000 25,000 Africa 258,672 22,656 66,672 21,408

Totals: 32,000 164,500 Americas 286,656 19,344 24,672 10,464

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

IDA Netherlands 325,500 South East Asia 446,976 32,448 1,646,544 258,672

Geneva 50,000 224,500 Western Pacific 46,848 2,784 3,936 1,392

Totals: 50,000 550,000 Totals: 1,075,536 80,256 1,749,120 294,096

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