3) Organization of Leprosy Services Under Low Endemic Conditions
Chair： Dr. P. Saunderson
1) What is meant by low endemic conditions?
We looked at three possible indicators of low endemicity, namely： case detection rate, registered prevalence and prevalence of disability. The workshop felt that case detection rate (CDR) would be the most appropriate measure to use as that indicates the actual number of patients requiring services and it also drives the other two indicators. A CDR equivalent to a registered prevalence of 1 in 10,000 is about 5 per 100,000 so we took a low endemic situation to be one with less than 5 new cases detected per 100,000 population per year. It was noted that the geographical distribution is such that many countries will have areas of very low endemicity and other areas with more patients (e.g. China, where the overall CDR is very low, but most leprosy occurs in 3 provinces).
The prevalence of disability may be the significant statistic in describing the leprosy workload in any area： the residue of disability is the major problem for the next millennium.
2) Case detection
Even in rich, low-endemic countries, leprosy patients often remain undiagnosed for a long time (4 - 6 years) ; it seems likely that as endemicity decreases the average delay in diagnosis will increase. In richer countries, leprosy patients are referred to dermatologists.
For poorer countries with a low endemicity, there will be a need to dismantle the vertical leprosy programmes and change to a policy of suspicion at the peripheral level and referral to specialized level for diagnosis and management of complications. The private and traditional sectors must also be involved in referring suspects.
3) Treatment
Accessibility is the main issue, with many patients living a long way from leprosy expertise. The provision of MDT could be linked to other programmes such as TB. Peripheral clinics could hold blister-packs for leprosy, according to the numbers treated in the previous year. For very distant patients, treatment can be given for 3-6 months at a time.
4) Management of reactions
Reactions are possible at any time in the five years or so after diagnosis. After discussion, it was felt that in low endemic situations in poor countries, it would not be possible to provide expertise in nerve function assessment at the peripheral level. As most patients would not be able to go regularly to the referral center, there must be a much improved methodology for educating patients to recognize symptoms of reactions and neuritis and voluntarily report for appropriate treatment. Such a system may involve former leprosy patients. The same person who is trained to diagnose leprosy should be trained to manage reactions and neuritis and prescribe steroids.
