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Country scene in Nagpur, India

Prescriptions for Success
With the goal of elimination set for the end of 2005, we asked four public health experts to take a moment and tell us how they view the current situation and what they feel needs to be done to make elimination a reality.

Awareness and Easy Availability of MDT Are Key
Dr. A.K. Choudhary
 
 
 Leprosy has been a public health problem in Bihar for many years. The Indian government launched a National Leprosy Control Program in 1955. In 1983, with success of MDT (multidrug therapy) in treatment of leprosy, the program was renamed the National Leprosy Eradication Program (NLEP). The infrastructure was further expanded to deliver leprosy services under two World Bank-supported projects from 1994 to 2000 and 2000 to 2004.
 In addition, from 1998 to 2003, four Modified Leprosy Elimination Campaigns (MLEC) were successfully conducted in Bihar. As a result, the leprosy prevalence rate has been reduced significantly from 52 per 10,000 in 1996 to 4.8 per 10,000 in November 2003.
 There are a number of specific factors that need to be urgently addressed. These include continuing the intensified effort toward community awareness, especially among women and underprivileged groups; providing annual orientation for general healthcare staff to sensitize them for leprosy work; improving coverage of MDT services beyond the government health setup; and strengthening sub-district supervision and monitoring of NLEP activities.
 Awareness and easy availability of MDT are the key to leprosy elimination. With this in mind, we can consider the following innovative approaches: active involvement of Panchayati Raj (local self-government) institutions at panchayat and village level; involvement of private medical practitioners from all systems of medicine in providing wider outreach for identification/diagnosis and treatment of leprosy; making panchayat members, local public representatives and opinion-makers responsible for leprosy elimination at panchayat/village level; and involvement of all medical colleges and district-level hospitals for reconstructive surgery.

Dr. A.K. Choudhary is Health Secretary for the Government of Bihar, India
 
Elimination Is Only an Intermediate Goal
Dr. Pieter Feenstra
 
 
 Now that leprosy has been placed high on the agenda of health ministries in leprosy-endemic countries, not only has the prevalence rate been reduced but as a result of improved and intensified leprosy services and the wide availability of MDT, an increasing number of cases are being found and treated.
 Despite these impressive results, however, the achievement of the elimination target is only an intermediate goal and the struggle against leprosy will have to be continued for many years to come. We must also accept that in a few countries, whether at the national or sub-national level, it will not be possible to achieve the target before the end of 2005 because of the high incidence of the disease. These countries should not be discouraged, but be stimulated and supported to sustain the fight against leprosy.
 The best and most effective tool we have is to diagnose leprosy in a timely manner and treat it with MDT. Therefore diagnostic and treatment services have to become accessible to all communities in areas where leprosy occurs. This is to be achieved by effectively integrating leprosy services within the general system, which is already the major element of WHO strategy.
 Even after the elimination target has been reached, these services have to be sustained. Moreover, childhood vaccination with BCG must be continued, as this reduces the risk of developing leprosy. In addition, chemoprophylaxis, which is currently under study in several trials, promises to become an important tool in the elimination of leprosy.

Dr. Pieter Feenstra is Senior Advisor for Public Health, Head, Leprosy Unit, Royal Tropical Institute (KIT), Amsterdam, The Netherlands
 
Integrate Leprosy as Health Unit Activity
Dr. Francisco Songane
 
 
 Over the past several years, the Mozambican government has intensified efforts to eliminate leprosy. Good collaboration between the Ministry of Health and various partners has been fundamental in making tools and funds available to win this battle. The important and valuable contribution of these partner organizations has been vital to countries such as Mozambique that would otherwise not have had the possibility of meeting the 2005 target.
 In spite of the fact that the leprosy burden is related to poverty and a low level of development, we have obtained some success not only with MDT but also with the easy clinical assessment that eliminates the use of laboratory skin smears.
 We launched two elimination programs in 1999 and 2000 for sensitizing and mobilizing communities for early detection and treatment; moreover, the most peripheral and endemic areas started to focus on important issues such as education of local authorities and training of health staff.
 In this way, we are working to improve case-finding and eliminate the stigma of leprosy by explaining that the problem has a solution and treatment is free.
 To achieve the 2005 goal, it is important that leprosy elimination be integrated as one of several activities in the health unit. Therefore, we will continue to train peripheral staff in order to have at least one trained person in each unit and three community volunteers in each village to search for leprosy and see that patients complete their treatment. Reinforcing the link between health units and villagers through community councils should be a priority.
 Innovative steps that should be taken include working with other important sectors that are well-placed in rural, peripheral and remote areas, such as the Ministry of Agriculture through its rural field workers; employing the Myanmar concept of training Mother and Child nurses in leprosy case-finding; and linking treatment with a food kit to benefit patients, who are normally poor, and so improve passive case-finding.
 Prevention of deformities is another priority, through the project of training general physiotherapists countrywide. Using handicapped people to make shoes for leprosy patients is one unconventional idea that is already in place to reintegrate patients with deformities.

Dr. Francisco Songane is Mozambican Minister of Health.
 
Sensitize and Mobilize Local Communities
Professor Andry Rasamindrakotroka
 
 
 Since Madagascar implemented the Leprosy Elimination Program in 1992, results have been encouraging, even though we have not yet reached the elimination target set for 2000. That is why we developed an intensified elimination plan covering the period 2001-2003.
 The implementation of leprosy elimination campaigns (LEC) and special action projects (SAPEL) in 1997-1998 allowed us to detect and treat many hidden cases in highly endemic areas. One of the weaknesses of the program was the difficulty of obtaining reliable epidemiological data because of the lack of follow-up of newly detected cases. The situation worsened in early 2002, due to political events that brought activities to a complete stop and negatively affected the intensified elimination plan. Activities resumed in mid 2002, including training of health workers and updating of registers.
 The following factors should be taken into account if elimination is to be achieved: training of health workers in prompt diagnosis and correct case management at all levels of the health system to ensure reliable data; strengthening of information, education and communication (IEC) activities to sensitize patients to get diagnosed early; improving collaboration between private and public health centers; and setting up an efficient communication system to ensure the smooth flow of information.
 There is also a need to bring the health system nearer to the population through the establishment of Mobile Health Teams to reach remote and land-locked areas. Twelve teams have been active since the end of 2003, and 12 more are expected to join them this year. Also, there is a need to ensure patients comply with the cure regimen by sensitizing and mobilizing local communities and providing them with appropriate logistical support, such as bikes and motor bikes.

Professor Andry Rasamindrakotroka is Madagascar's
Minister of Health and Family Planning.
 

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