Leprosy Elimination in Brazil

Leprosy Mailing List – January 20^th, 2012

Ref.:    Leprosy Elimination in BrazilFrom:  D Lockwood, London, UK

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Dear Salvatore,

Apologies for making a late contribution to this debate and a Happy New Year to all LML readers.  I would like to thank Piet for making a range of useful comments about the elimination strategy.  It is important that we should discuss the elimination strategy and its strengths and weaknesses because we can then use the parts that worked and develop alternatives for the aspects that did not work. 

The lack of an evidence base for the policy of elimination has been critical in the campaign and modelling by Jan Richardus [1] shows that leprosy cases will continue to present for decades yet.  Studies in Bangladesh [2] and India [3] have shown that there are still many undetected cases of leprosy in the community.  India reached the elimination level partly through the application of changes in case finding and registration.  India has now had a national sample survey to estimate how many leprosy patients there are.  This has revealed many undiagnosed patients and a substantial burden of disability.  India is thus after an apparently successful elimination strategy having to work out a way of acknowledging that in some states the strategy was not successful.  It is important to understand the reasons why elimination has not worked in the most endemic areas and develop new ways of detecting and treating patients rather than striving to reach a target of fewer patients.

The previous Brazilian leprologists were very honest in admitting that Brazil had not reached the elimination target in 2005 and the recent high numbers of leprosy patients being reported from Brazil is a testament to the strength of the programme in that it is doing what an infectious disease programme should do which is detect and treat all cases.  It is therefore most unfortunate to describe this instead as a failure to reach elimination.

The perception of elimination has reduced research and innovation in leprosy.  The recent ILEP review highlighted several important research areas that need studies to provide evidence for our treatments and policies.[4]

The other problem of elimination as a public health problem is that it creates the perception that leprosy is really eliminated and that future training is not needed.  This is an important consequence when leprosy cases in future will have to be diagnosed by a range of health workers.

Best wishes,

Diana Lockwood

Professor of Tropical Medicine

London School of Hygiene & Tropical Medicine
Keppel St London WC1E 7HT, UK

References

1. Fischer EA, de Vlas SJ, Habbema JD, Richardus JH (2011) The long-term effect of current and new interventions on the new case detection of leprosy: a modeling study. PLoS Negl Trop Dis 5: e1330.

2. Moet FJ, Schuring RP, Pahan D, Oskam L, Richardus JH (2008) The prevalence of previously undiagnosed leprosy in the general population of northwest bangladesh. PLoS Negl Trop Dis 2:e198.

3. Shetty VP, Thakar UH, D'Souza E, Ghate SD, Arora S, et al. (2009) Detection of previously undetected leprosy cases in a defined rural and urban area of Maharashtra, Western India. Lepr Rev 80: 22-33.

4. van Brakel W, Cross H, Declercq E, Deepak S, Lockwood D, et al. (2010) Review of leprosy research evidence (2002-2009) and implications for current policy and practice. Lepr Rev 81:228-275.