Why Brazil is doing this?

Leprosy Mailing List – December 10^th, 2011

Ref.:   Why Brazil is doing this?
From: W C S Smith, Aberdeen, Scotland, UK

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Dear Salvatore,

Can I respond to your message (LML Dec. 4th, 2011) from a personal perspective?  Much of what you say about incidence, prevalence and elimination is correct, and is re-visiting old debates.  I am very aware of the debates and misgivings about the term elimination.  Correctly the ‘elimination strategy’ was defined in the World Health Assembly 1991 resolution as elimination as a public health problem to a registered prevalence of less than 1 in 10,000 population at a global level by the year 2000.  The elimination strategy was highly successful in providing a focus for leprosy and in securing political and financial commitment leading to a dramatic reduction in registered prevalence by the end of 2000.  Since then the global strategies have focused more on reducing the burden of disease, new case detection, improving quality of leprosy services and reducing disabilities. 

Public health strategies and policies with targets are developed, based on many factors as well as the epidemiology.  Many of the weaknesses of prevalence you have mentioned also apply to new case detection which limit its validity as an indicator of ‘incidence’.  Prevalence can be a useful indicator of treatment workload for programme managers.  Now that treatment duration is 6 or 12 months, the prevalence approximates to new case detection.  Indeed where the duration of MDT is fixed, and it is efficiently delivered with good completion rates, new case detection is the main determinant of prevalence according to the mathematic formula. 

As to the situation in Brazil – this is a country that, according to the Weekly Epidemiological Record, is in the rather unique position of not yet achieving a registered prevalence below 1 in 10,000.  If the government wants to develop an ‘elimination strategy’ that would improve the quality and coverage of the national programme that should be welcomed – the name is of less importance and I am very aware of the problems with that word.  If the multidrug therapy (MDT) programme in Brazil is efficient (the prevalence/new case detection ratio is less one in Brazil which suggests the MDT programme is efficient) then the only way to reduce registered prevalence will be by reducing new case detection.  I would hope that the strategy would also include the key components of the WHO ‘Enhanced Global Strategy’ which includes a focus on new case detection, reduction in disabilities, participation of people affected by leprosy, and addresses issues of human rights and discrimination.  The heart of the issue is not the title but whether this policy is going to have a positive effect on the health and wellbeing of people affected by leprosy?  If yes, then we should work together to support the efforts of the Brazilian leprosy programme.

With best wishes,

Cairns

W Cairns S Smith OBE, MD, MPH, PhD

Emeritus Professor of Public Health,

School of Medicine and Dentistry,

University of Aberdeen,

Polwarth Building,

Foresterhill,

Aberdeen AB25 2ZD,

Scotland, UK

Telephone - (44) 1224 437266

Email: w.c.s.smith(at)abdn.ac.uk