Elimination of leprosy as a public health problem at the global level in the year 2000 was a significant milestone in history. Though the prevalence has come down to less than one case per 10 000 population globally, new cases are being reported from more than 100 countries. As per the leprosy statistics published by WHO in 2014, 215 656 new leprosy cases were detected worldwide. The WHO South-East Asia Region alone contributed 155 385 cases, 72% of the global leprosy case count. Leprosy is not uniformly distributed across the world; 96% of leprosy is limited to 15 countries, which report more than 1 000 new cases annually. Even in these high endemic countries, high leprosy prevalence is recorded in certain endemic pockets, usually referred to as ‘hotspots’. A small proportion of patients having visible deformities in their hands, feet and eyes due to delayed detection, experience stigma associated with disfigurement. Globally, 13 289 such new cases with visible deformities or grade 2 disabilities were detected in 2013. One in every ten new leprosy patients is a child. This fact needs greater attention, as it causes childhood disabilities not unlike polio. Globally, 19 796 new cases of leprosy were found in children. These numbers are totally unacceptable and call for a review of the leprosy programmes. We need to focus on the remaining leprosy “hotspots” with renewed and invigorated efforts. An efficient treatment protocol for leprosy was introduced by WHO in the early 1980s. There is no reason why a person should suffer deformities and stigma from leprosy today.
One of the oldest diseases known to humanity, leprosy is still attributed to causes like the curse of God and result of past sins and so on. It continues to remain a target of myths and misconceptions. Occasionally, instances of persons affected being separated from their familiesand isolatedin a remote place or an island in some countries are reported, albeit, in small numbers.
The stigma attached to the disease and low levels of awareness in the community about it add to deterrence in early detection and treatment of leprosy, which is the only time-tested way to completely reduce leprosy cases to ‘zero’. An untreated patient is a source of infection. Leprosy transmits to a healthy individual through air or skin-to-skin contact with an infected person. It takes several years for a susceptible person to acquire the disease. The earliest symptom of leprosy is a skin patch and loss of sensation. In the absence of any discomfort at the outset, an affected person tends not to report the patch.
WHO introduced the multidrug therapy (MDT) in the early 1980s as the main treatment protocoli. MDT has multiple benefits; the infected person ceases to be infective with a single dose; it is a complete treatment for leprosy; and it reduces the risk of disabilities and consequent stigma. MDT eventually reduces treatment costs on the health system. Over 16 million patients from 125 countries across the globe have been treated with MDT which helped rapidly reduce the prevalence of the disease to less than one case per 10 000 population at national levels for leprosy to be declared as eliminated in the year 2000. As of today, MDT regimen stands as a robust protocol. In addition, WHO makes MDT available free of cost in all countries.
Now that the number of leprosy cases has come down from 11 million in 1983 to under a quarter million, we need to renew our commitment for the last mile in completely eliminating this disease from the world.
It is time for the leprosy programmes to re-energize to focus on the remaining leprosy endemic areas or “hotspots”. Detection of leprosy in children is an evidence of continued transmission of the disease in the community, while grade 2 disabilities indicate delayed detection of the disease. We now need to work towards ‘zero child cases with visible deformity or grade 2 disability by 2020’ and detecting all ‘new leprosy cases before disability’. Focused case-finding activities should be rolled out in these areas for early detection of cases and complete treatment with MDT; they still are the basic tenets of leprosy control in the community. Enhanced global strategy to reduce disease burden due to leprosy which is currently implemented in countries endemic to leprosy emphasizes early detection and complete treatment. Breaking the chain of transmission between the patients and healthy population remains ‘the strategic choice’ for controlling leprosy.
Also, there is need for further research. Resistance to antimicrobials, particularly rifampicin, is an imminent risk. Though the frequency is low as per the available data, its impact on the success of MDT could be substantial. Recognizing the need, WHO spearheaded an initiative of developing a network of sentinel centres to monitor the occurrence of drug resistance to leprosy in all leprosy-endemic countries. Till now, the results from the sentinel centres are very encouraging. The incidence is low and WHO believes in continuing such surveillance to sustain the gains achieved by MDT in controlling leprosy.
Globally, more than 200 000 new cases have been detected every year for the past five years in spite of leprosy control efforts. To overcome the challenges in reducing the occurrence of new cases, the health ministers from 17 endemic countries committed to the Bangkok Declaration in 2013 which re-affirmed political commitment and urged countries to enhance efforts to reach the unreached populations. The Bangkok Declaration also includes leprosy-affected persons in the leprosy control activities. The persons affected by leprosy are recognized as a great resource; their involvement helps in early case detection and reduction of stigma. International agencies and partners in leprosy control pledged their continued support to the leprosy programme in the summit.
To move towards endgame leprosy, WHO is developing a new global leprosy strategy for 2016–2020 to detect all cases before disability and achieve zero disability cases among children. The Nippon Foundation, Novartis Foundation for Sustainable Development (NFSD), International Federation of Anti-leprosy Associations (ILEP) and the networks of persons affected by leprosy are joining forces with a commitment to support the leprosy programme with funds and MDT supply until 2020. The nongovernment organizations at national and sub-national level are supporting leprosy programme activities to achieve ‘Zero child cases with disabilities due to leprosy’.
Every person has a role to play in reducing the leprosy disease burden and removing this age old scourge from the globe. We need to enhance awareness about the early signs of the disease, make MDT available and encourage acceptance of the affected at home, school or at the workplace. These coordinated efforts would improve early case detection and help us reach the goal of ‘zero child cases with visible deformity or grade 2 disability by 2020’.
i WHO study group on Chemotherapy of leprosy control programmes, 1981.