Addressing successful leprosy control in Guyana
Viewpoint by Dr. H. Alexander
January 31, 2004
THROUGH the centuries leprosy has remained a feared disease with severe social repercussions for suffers. Until World War II, no effective treatment was known and health authorities had to resort to segregation to prevent spread of the disease. In 1947, Dapsone tablets became the mainstay of leprosy treatment. It was hoped that patients would be cured and leprosy could be eradicated. However, this proved not to be the case. In 1960 it became dear that relapses occurred even after regular and prolonged treatment and in the 1970s Dapsone resistance became a real problem.
In the meantime, new drugs had become available, notably dofazimine and rifampicin. Rifampicin in particular proved to be extremely effective, killing 99.9% of M. Leprae with a single dose of 600 mg. Under the auspices of ILEP and later the WHO, experts designed a new drug regimen. Multiple Drug Treatment (MDT) was introduced in 1982. This treatment was to be given for at least 24 months or until the bacteriological index (BI) was negative. Since a considerable number of patients were unable to comply with the duration of treatment specified, its length was changed of 6 monthly doses for PB patients and to 24 monthly doses for MB patients. These regimens proved to be extremely effective, relapses were unexpectedly rare.
The number of the registered leprosy cases declined from 5 million in the mid 1980s to a little more than 800 000 to date a reduction of 85%.
For the first time both patients and health workers began to believe that leprosy might be cured. This resulted in more effort by health workers to detect and treat patients, whereas those afflicted with leprosy came forward earlier, often before developing severe nerve damage.
Encouraged by the efficacy of these treatment regimens, in 1991 the 44th World Health Assembly established the goal of eliminating the disease by the year 2000. The WHO goal has been achieved in many countries, including Guyana. But certainly not in those where 85% of all known leprosy patients live, notably India, Brazil, Nigeria, and Indonesia.
Although the treatments turned out to be very effective, problems were encountered. Operationally, it was not always possible to reach all patients regularly and in time and not all patients were able to finish the prescribed treatment within the allocated time and therefore could not be released from treatment. Some patients objected to the clofazimine color showing in their skin, some became anaemic from dapsone and a few developed 'flu-reaction'. However, the treatment proved acceptable and safe overall.
Over the past decade the diminishing stigma associate with leprosy has resulted in a better outlook for the patients. Public understanding has increased considerably. Unfortunately, this goal has led many to believe that leprosy has been or will be eradicated soon. This will certainly not happen in the near future. Despite the fall in the number of registered patients, the number of new cases registered world wide each year changed little and remained constant at about 600 000 cases world wide and at 20 to 25 new cases in Guyana until 1995. Thereafter, numbers steadily increased to 800 000 cases detected in 1998, our average in Guyana is now 30 to 35 new cases detected per year.
The number of patients under treatment in leprosy programs declined so markedly that their cost effectiveness became jeopardized. This and the authorities' belief that leprosy is nearly eradicated led to dismantling of leprosy services. Some are combined for practical purposes such as drug delivery with tuberculosis control, others are integrated in the general health services as we in Guyana attempted to do.
In 1998 the WHO Expert Committee on Leprosy convened to review the global situation to identify the remaining obstacles of eliminating leprosy as a public health problem. On the basis of field trials and clinical studies, the committee concluded that a single dose of a combination of rifampicin, ofloxacin and minocycline (ROM) is an acceptable and cost effective regimen for the treatment of single lesion leprosy and that the duration of the current MDT regimen for MB leprosy could be shortened to twelve months.
These new recommendations will certainly help to achieve the goal set by the World Health Assembly. By shortening the duration of treatment the number of patients on register will reduce especially in countries such as Brazil, Indonesia and India, which have a high percentage of patients. Therefore, the recommendations will satisfy the politicians. However, are they beneficial to the individual patient or leprosy control programs? I certainly do not think so.
A major problem in leprosy is the occurrence of nerve damaging reactions. Data on leprosy patients show that, after 24 months of MDT, 14% developed reactions. In terms of twelve months at least 26% of patients can be expected to develop reaction. This implies that one quarter of patients is at risk of becoming more disable after being considered cured! Moreover, whether or not twelve months of treatment will be effective in inducing lasting remission in highly bacillferous patients still remains to be demonstrated.
Vertical leprosy services with more or less experienced workers are presently being dismantled and integrated in other serves, partly due to the success of MDT. The overburdened Primary Health Care worker do not have time to deal with complicated cases and is often not well equipped to do so. Moreover, the knowledge of a peripheral health workers or a clinic attendant is inadequate to handle leprosy issues.
If and when leprosy control is fully introduced into the Primary Health Care service in Guyana, the number of patients disabled because of leprosy will probably grow, as it is unlikely that the knowledge and experience on diagnosis and treatment of leprosy and its complications will survive in an integrated health service where leprosy constitutes but a small part of the program. Thus, leprosy remains a problem for the afflicted. This Guyana situation should not be ignored.
My view is that a dermatological service within the general services is a viable solution. Since leprosy is a neural disease with expression in the skin, workers who do inspection of the skin are best equipped to detect early cases, relapses and reactions. What we need in Guyana are at least a few trained Dermatologists in every region if we are to successfully introduce Leprosy control into the primary health care service.
(Courtesy of GBC)