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—from the Epidemiological Bulletin, Vol. 21 No.1, March 2000— Elimination of Leprosy in the AmericasTwo conferences on the elimination of leprosy in the Region of the Americas and in the world took place during the month of November 1999. The Third PAHO/WHO Regional Conference on the Elimination of Leprosy from the Americas was held in Caracas, Venezuela from 3 to 5 November, in order to define a plan of action for the Region of the Americas. Convened by WHO from 15 to 17 November, the Third International Conference for the Elimination of Leprosy took place in Abidjan, Ivory Coast, and led to the announcement of the “Global Alliance to Eliminate Leprosy as a Public Health Problem in every country by the year 2005.” This initiative will give the effort against leprosy its final impulse. The implementation of multidrug therapy (MDT) has dramatically changed the epidemiological situation of leprosy in the Region of the Americas. The number of registered cases decreased from 369,846 in 1992 to 88,053 in 1999, while the detection rate per 10,000 population slightly increased at the regional level in the same period, with important progress in some countries such as Brazil. The geometrical mean of the annual decrease of the prevalence rate, now at the level of 18.7%, also reflects a decrease in the number of countries where leprosy is a public health problem, from 14 to 2 in Latin America (1) (Brazil and Paraguay), and from 27 to 3 in the American continent as a whole. The elimination of leprosy from the Americas by the year 2000, through a decrease of the prevalence rate to a level below 1 case per 10,000 population, is a reachable goal that involves a reduction in the current number of registered cases of less than 10% in most countries. In the case of Brazil, where the reduction from 75,000 to 16,000 registered cases is more significant, leprosy could be eliminated within 3 to 4 years. The countries of the American Region can be classified into the five following groups, based on different levels of priority and according to criteria such as prevalence rate, absolute number of registered cases and newly detected cases in 1998: - Group 1: Brazil. This country is a top priority since it represents
between 80 and 90% of the total burden of leprosy in the continent. Consequently,
special and intensified efforts will be required to eliminate the disease
through the active involvement of municipalities. In the case of Latin America, due to the socioeconomic situation and some characteristics of the national health systems, it is reasonable to suspect that the elimination programmes did not detect all of the existing cases in the area. Consequently, a hidden prevalence could exist, which can be estimated from the characteristics of the newly detected cases. Its importance was characterized in the following study, which includes some countries of Latin America only, due to the lack of data for the other countries. In a group of 9 Latin American countries (2) representing around 80% of the population and of the leprosy prevalence in all the countries where leprosy was eliminated at the national level, the hidden prevalence was estimated at 5,000 cases. From this figure, it can be estimated that there are about 7,000 unknown cases in Latin American countries that have already eliminated leprosy, i.e. excluding Brazil and Paraguay. In order to emphasize the importance and priority of the leprosy problem in areas where the elimination at the national level has already occurred, another group of 8 Latin American countries3 where leprosy was eliminated was considered. Again, this sample included 80% of the population and of the leprosy prevalence in all the countries with eliminated leprosy at the national level. In these countries, approximately 30 million people live in the territories of the first sub-national level (state, province or department) where leprosy has not been eliminated. Thus we can estimate that about 40 million people live in areas where leprosy is still a public health problem, in countries of Latin America where leprosy is considered to be eliminated at the national level. Further, of the 191 entities forming the first sub-national level, 37 (19%) have not eliminated leprosy. Therefore, elimination strategies should be sustained even when a given country has reached elimination of leprosy at the national level. Two steps are involved in the integrated approach to insure political commitment and technical cooperation: - The first step is confirmation, with prevalence as an indicator. In the confirmation stage, entities are classified according to their respective estimated prevalence rate and different strategies are put in place in order to evaluate hidden prevalence. Once the search and evaluation of the hidden prevalence are achieved, if it is confirmed that the prevalence is below one case per 10,000 population, other strategies will be implemented in order to confirm this “status”, using detection (incidence) as an indicator through the promotion of community awareness and training of local health teams. - At a later stage, when no case is detected after a five-year period, the progressive introduction of an epidemiological surveillance system adequate for a low prevalence scenario is proposed, using tools such as sentinel surveillance and zero reporting, until the interruption of transmission is reached, which means that the area is no longer endemic for leprosy. The “Global Alliance” proposed the following key strategies for the 2000-2006 period: 1) implement the diagnostic and treatment of leprosy in all the services of the endemic area; 2) guarantee the availability of free MDT treatment in health centers through appropriate logistic; 3) motivate people to ask for treatment, through creative and higher quality interventions, to spread the information on signs and symptoms of the disease; 4) ensure high healing indices through the introduction of innovative and flexible systems of administration of MDT; and 5) monitor actively the situation to adopt appropriate actions to solve the detected problems rapidly. In order to accelerate progress towards elimination of leprosy in Brazil, Paraguay and Suriname and to build innovative strategies to validate and consolidate the results obtained in the other countries, a pro-active and sustained effort is proposed, through the implementation of a Regional Plan coordinated by PAHO/WHO. As agreed during the Vene-zuela conference, this action plan will be elaborated in 2000. From the time of its formulation, it should count on the full commitment of a wide spectrum of partners, and a close collaboration between health care providers and users at every level of leprosy care. The objectives of the Regional Plan should be to prevent the re-emergence of the disease as well as, through the use of new technologies, the total interruption of its transmission, i.e. the eradication of leprosy from the Americas.
(2) Argentina, Bolivia, Colombia, Cuba, Dominican Republic, Ecuador, Mexico, Peru and Venezuela (3) Argentina, Bolivia, Colombia, Cuba, Mexico, Peru, Dominican Republic and Venezuela
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