In the DRC, the work of community agents is leading to a significant improvement in new-case detection.

　

The Democratic Republic of Congo remains one of the world's most leprosy-endemic countries. The chief obstacles in the way of eliminating leprosy are poor health-services coverage, a situation exacerbated by armed conflict, and the lack of community involvement, especially at village level, in leprosy elimination activities.
　In order to speed up the DRC's efforts to achieve the elimination goal, we have adopted some innovative approaches to detect hidden cases in villages and treat them correctly.
　Our method has been to intensify elimination efforts in a number of highly endemic districts identified in 2002 by extending the activities of community agents (known as relais communautaire) to the village level (and, in cities, to the street level).

　

　The community agent is a volunteer chosen by villagers (or by the inhabitants of a city street) who agrees to act as a link between the local community and the health services. On average, one community agent serves 200 to 300 people, and there are between one and three community agents per village.
　Adopting the community agent approach also helps address another issue ― the poor utilization rate of health services. In the DRC, this rate is between 15% and 20%, and represents a significant obstacle in the way of detecting leprosy cases.
　The agent's role is to sensitize villagers about leprosy; direct those suspected of having the disease (based on an initial diagnosis involving sensation testing of skin patches) to the nearest health center; follow the progress of patients taking MDT and make sure they complete their full course of treatment; and look out for leprosy complications or reactions so that the persons affected can receive further treatment at the health center.
　Following the implementation of this strategy, we have seen a spectacular improvement in the number of cases detected, especially in the areas covered by the five projects shown (Table 1).
　This indicates that we had previously underestimated the scale of the problem, as the strategy has uncovered a large number of hidden cases stemming from the lack of access to healthcare services.
　The improvement in case detection (Table 2) has not been without challenges, however. In a shattered country such as DRC, the notion of voluntary service is difficult for many people to comprehend, so it is necessary to provide community volunteers with incentives. These include loincloths, hoes and T-shirts for women, and fishing nets, hatchets, machetes and T-shirts for men.
　Also, the increase in case numbers has imposed a strain on MDT stocks, and there have been frequent disruptions in supply that we are working to address.
　Turning to community agents has enabled us to tackle a crucial shortcoming of our program, as previously we had not made sufficient use of social mobilization and community involvement at the provincial and peripheral levels.
　Integrating the community agent approach into our leprosy control activities gets villagers involved through their interaction with the community agent, which aids in detecting cases at the village level.
　In this way, we can reach areas that are without proper health coverage, which is essential if we are to detect and treat all hidden cases.