World Health Organization

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 2007 World Health Organization Regional Office for the Western Pacific Manila, Philippines With data available as of December 2005

PREPARED BY The Stop TB and Leprosy Elimination Unit in the WHO Regional Office for the Western Pacific, Pieter van Maaren and Sumana Barua, in collaboration with Dr Arturo C. Cunanan, Jr., WHO Consultant ACKNOWLEDGEMENTS We would like to thank all national leprosy programme managers and statisticians from all the countries and areas of the Western Pacific Region for providing appropriate data for this document. WHO Library Cataloguing in Publication Data Epidemiological review of leprosy in the WHO Western Pacific Region, 2007. 1. Leprosy - epidemiology. 2. Western Pacific. ISBN 978 92 9061 315 2 (NLM Classification: WC 335) World Health Organization 2007 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them - whether for sale or for noncommercial distribution - should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: publications@wpro.who.int. Updated information on leprosy in the Western Pacific Region is available at: http://www.wpro.who.int ii

CONTENTS 1 SUMMARY... 2 INTRODUCTION... 3 ACHIEVEMENTS... 4 EPIDEMIOLOGICAL SITUATION... 5 PROGRAMME ACTIVITIES... 6 ISSUES AND CHALLENGES... 7 FUTURE PRIORITIES AND ACTIVITIES... 8 RESOURCE REQUIREMENTS... 1 5 6 7 15 18 20 22 FIGURES AND TABLES Figure 1 Leprosy prevalence rates and multidrug therapy in the Western Pacific Region (1988 2005) Figure 2 Distribution of new cases of leprosy detected in 2005 Figure 3 New case detection rates per 100 000 population in 2005 Figure 4 Distribution of registered cases and the prevalence rates per 10 000 for eight countries in the Western Pacific Region (2005) Figure 5 Trend of prevalence and new case detection rates (1991 2005) Figure 6 Trend of prevalence rates after elimination in some large countries and areas Figure 7 Trend of new case detection rates after elimination in some large countries Figure 8 Trend of prevalence rates after elimination in some small countries and areas Figure 9 Trend of prevalence rates in two countries that have not yet achieved the elimination target in the Western Pacific Region 5 8 9 10 13 14 14 14 20 Table 1 Table 2 Table 3 Table 4 Latest notification of leprosy cases and monitoring indicators by countries and areas, 2005 Distribution of countries as to attainment of elimination target in 2005 Proportion of MB, disability grade 2, and children below 15 years among new cases (1994 2005) Trend of the prevalence and new case detection, Western Pacific Region (1991 2005) 3 7 11 13 iii

ABBREVIATIONS HEC KAP LEC LEM MB MDT NGO P/D ROM WHO Health education campaign Knowledge, attitudes and practices Leprosy elimination campaign Leprosy elimination monitoring Multibacillary Multidrug therapy Nongovernmental organization Prevalence/detection ratio Rifampicin-Ofloxacin-Minocycline World Health Organization iv

1 SUMMARY This epidemiological review of Leprosy 2005 in the Western Pacific Region of WHO is based on information collected from 37 countries and areas of the Region, as well as other sources. A total of 30 countries and areas have sent annual leprosy data for 2005 (Table 1). The population, prevalent cases, and new cases reported of the six countries and areas that did not send their data was 20.8 million, 13 million, and 17 million, respectively. The estimated population of the Region for the year 2005 was 1.74 billion. Of the 33 countries and areas that eliminated leprosy as a public health problem (defined as the prevalence of less than one case per 10 000 population) at the end of 2004, all 33 countries and areas have sustained elimination status in 2005. Kiribati had lost its elimination status due to the detection of a large number of new cases, following the launching of a leprosy awareness campaign and active case detection activities in 2003, but reduced the prevalence rate by 47% in 2005. Leprosy has continued to be a public health problem in the Federated States of Micronesia and the Marshall Islands. Yet eight countries and areas have reported zero prevalence and new case detection. The registered cases at the end of 2005 were 9460, with a prevalence rate of 54 per 10 000 population. The prevalence rate continued to decline by 5.2% compared to that of 2004 and by 87.4% compared to that of 1991 when the Region attained the elimination goal. Ten countries and areas reported less than 10 registered cases, while only two (China and the Philippines) had more than 1000 registered cases. There were 7201 new cases reported in 2005, with a new case detection rate of 0.413 per 100 000 population. The new case detection rate has increased by 14% compared to 2004. This increase is artificial and may be attributed to the intensified case finding and awareness campaign activities in Kiribati, the Federated State of Micronesia, the Philippines, and the Solomon Islands. The prevalence/detection (P/D) ratio at 1.3 showed a marginal decrease in 2005. However, in countries and areas such as China, Malaysia, the Republic of Korea, and Singapore, patients are being managed with multidrug treatment regimens of longer duration than recommended by WHO. During the year 2005, health education and leprosy awareness campaigns and rapid surveys of endemic pockets were completed, in addition to screenings of selected populations in Kiribati, the Federated States of Micronesia, the Philippines, and Solomon Islands, resulting in the detection of significant numbers of new cases. 1

The biregional strategy developed in 2004 to sustain leprosy services following elimination was introduced in 2005 in Cambodia and Viet Nam by organizing national level workshops. A plan of action was developed to further reduce the disease burden by focusing on high endemic pockets at the subnational levels and by addressing problems pertaining to physical, social, and economic rehabilitation of leprosy-affected persons in the coming years. The regional prevalence rate, which had reached elimination level in 1991, has declined continuously thereafter. First and second level sub-national elimination has been achieved in big countries like Cambodia, China, the Lao People s Democratic Republic, the Philippines (except for a few provinces and cities), and Viet Nam. The new case detection rate which fluctuated soon after elimination has started to decline from 1998 levels; however, the rate of fall of both prevalence and case detection are slowing down since 2004, with a marginal increase in the case detection rate in 2005. A similar picture is also emerging in countries and areas such as Cambodia, the Lao People s Democratic Republic, the Philippines, and Viet Nam after reaching the elimination target. In China and in the Republic of Korea, elimination was accomplished prior to 1991; with an initial fall after reaching elimination, both prevalence and case detection rates have stagnated since 1997. As such, quality leprosy control activities that are integrated into the general health services, as outlined in the biregional strategy, would be pursued in the aim of sustaining elimination and leprosy services in the coming years to further reduce the disease burden and prevent resurgence of the disease. 2

TABLE 1 Latest notification of leprosy cases and monitoring indicators by countries and areas, 2005 Country American Samoa (2004) Australia (2004) Brunei Darusalaam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republic of Korea Lao P.D.R. Macao (China) (2003) Malaysia N. Mariana Is. (2003) Marshall Islands Micronesia, F.S. Mongolia Nauru New Caledonia (2003) New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands (2004) Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna (2003) Summary Population X 1000 65 20 155 374 14 071 1 315 844 18 848 257 170 7041 128 085 99 47 817 5924 460 25 347 81 62 110 2646 14 237 4028 1 20 5887 83 054 185 4326 478 1 102 10 211 84 238 15 1 752 283 Prevalence New Case Detection * Proportion of Multibacillary (MB) cases ** Proportion of cases with grade 2 disability among new cases *** Proportion of children younger than 15 years among new cases **** Ratio between prevalent cases at the end of the year and the number of new cases detected during the year Denominator is based on the exact population estimate 19 907 Figures in ( ) indicate year of latest available data No. 4 0 1 348 3171 0 5 16 9 32 3 19 420 140 1 759 8 37 158 0 0 0 0 0 2 536 3096 0 5 25 21 0 0 0 2 642 0 9460 Rate x 10 000 0.62 0 3 0.25 2 0 6 0.62 0.53 5 002 1.91 9 0.24 2 0.30 0.99 5.97 14.30 0 0 0 0 0 0.99 0.91 0.37 0 0.27 6 0.44 0 0 0 9 8 0 54 Rate x No. 100 000 3 4.62 5 2 1 0.27 429 3.05 1658 0.13 0 0 4 0.47 10 3.90 6 3.54 4 6 6 0 34 34.22 15 3 143 2.41 1 0.22 263 1.04 4 4.95 44 71.01 260 235.32 0 0 1 7.33 4 1.69 2 5 0 0 2 13 381 6.47 3130 3.77 0 0 7 3.78 13 0.30 25 5.23 0 0 0 0 0 0 0 0 746 0.89 0 0 7201 0.41 MB* % 66.7 80 70 89.1 75 50 100 100 83.3 32.4 100 76.2 100 67.3 75 50 30 100 50 100 54 94.3 100 54 64 61 81.4 Dis** % 2 14.4 21.3 27.0 14.0 100 3.0 0.78 14.4 1.5 28.6 16.2 9.35 Child*** % 9.1 2.1 25 16.7 32.4 6.7 5.6 6.1 25 32.3 25.0 50 29 5.1 28.6 28 6.3 7.41 P/D**** Ratio 1.3 1.0 0.81 1.91 1.25 1.6 1.5 8 0.5 0.56 28 0.98 1.0 2.9 2.0 0.84 0.61 1.0 1.41 0.99 0.71 1.92-0.86 1.31 3

4

2 INTRODUCTION The Western Pacific Region comprises 37 countries and areas, with an estimated population of 1.74 billion in 2005. The Region contains both populous countries such as China and Japan, representing 75% and 7% respectively of the total regional population, and 22 very small countries and areas, representing 0.5% of the total population. Eight countries and areas have populations of more than 10 million and six have populations between one and 10 million. Of the remaining 23 countries and areas with populations of less than one million, seven have populations of more than 200 000 and 16 have populations of less than 200 000, of which seven have 20 000 or less. Countries and areas are scattered in the north, west, central, and south Pacific. The introduction of multidrug therapy (MDT) for treatment of leprosy in the 1980s and the adoption of a resolution by the World Health Assembly in 1991 for elimination of leprosy as a public health problem considered to be a prevalence rate of less than one case per 10 000 population were important landmarks in combating the disease. Although the elimination goal was achieved at the global level by the end of 2000, a few countries and areas have not reached the elimination target at their national level. In 1999, the target date for reaching elimination was extended to 2005, but six countries and areas still failed to attain the elimination goal. In the Western Pacific Region, MDT implementation began in 1985. It reached 10% coverage in 1988 and almost 100% by 1994, coinciding with a continuous decline in prevalence rate (Figure 1). FIGURE 1 Leprosy prevalence rates and multidrug therapy in the Western Pacific Region (1988 2005) 5

3 ACHIEVEMENTS n The prevalence rate at the regional level further declined by 5.2%, while the new case detection rate increased by 14% compared to 2004. n Elimination status was sustained in 33 countries and areas that have attained elimination, with only three countries and areas (Kiribati, the Marshall Islands, and the Federated States of Micronesia) still to reach the elimination target in 2005. n National leprosy awareness campaigns launched in Kiribati, the Marshall Islands, the Federated States of Micronesia, Papua New Guinea, the Philippines, and Solomon Islands, were assisted and followed up. n Special projects, such as the knowledge, awareness and practices (KAP) survey, the health education campaign (HEC), and rapid surveys of endemic pockets, were implemented in Cambodia, Kiribati, and the Federated States of Micronesia; and a leprosy elimination campaign (LEC) was implemented in the Philippines. n A geographic information system (GIS) has been established in Viet Nam and Cambodia. n The implementation of the strategy to sustain leprosy services following elimination, formulated in the 2004 biregional meeting of the WHO Regional Office for the Western Pacific and the WHO Regional Office for South-East, was started in Cambodia and Viet Nam. 6

4 EPIDEMIOLOGICAL SITUATION Table 1 summarizes the latest available data on leprosy by countries and areas, as of the end of 2005. Of 37 countries and areas, 30 sent data using the annual statistics form of the WHO Regional Office for the Western Pacific or the format communicated by WHO Headquarters. The seven counries and areas that did not send data cover 20.8 million of the Region s population, 13 million prevalent cases and 17 million new cases. 4.1 ELIMINATION AT REGIONAL, NATIONAL AND SUB-NATIONAL LEVELS Elimination at the regional level was achieved in 1991 with only 15 countries and areas reaching elimination at their national level, increasing to 35 by the end of 2000. Only two countries in the region, the Marshall Islands and the Federated States of Micronesia, have yet to achieve elimination. One country, Kiribati, has failed to sustain elimination since 2004 (up to the end of 2005) due to detection of a large number of new cases following a leprosy awareness campaign and active case detection by screening school children and populations in high endemic pockets. A country or area with a small population (less than 100 000) that has fewer than 10 registered cases is considered to have achieved elimination (Table 2). To date, 99.98% of the regional population lives in countries and areas that have eliminated the disease as a public health problem. TABLE 2 Distribution of countries as to attainment of elimination target in 2005 Thirty-four countries and areas achieved and sustained elimination, representing 99.9% of the Regional population: American Samoa, Australia, Brunei, Cambodia, China, Cook Islands, Fiji, French Polynesia, Guam, Hong Kong (China), Japan, the Lao People's Democratic Republic, Macao (China), Malaysia, Mongolia, Nauru, New Caledonia, New Zealand, Niue, the Commonwealth of the Northern Mariana Islands, Palau, Papua New Guinea, the Philippines, the Pitcairn Islands, the Republic of Korea, Samoa, Singapore, Solomon Islands, Tokelau, Tonga, Tuvalu, Vanuatu, Viet Nam, and Wallis and Futuna Two countries that did not yet achieved elimination and one country that failed to sustain elimination: The Marshall Islands, the Federated States of Micronesia, and Kiribati Sub-national elimination has been reached at the regional level in the Philippines, at the provincial level in Cambodia, the Lao People s Democratic Republic, and Viet Nam, and at the county level (except in a few counties) in China. However, these five countries contributed 78% of the total prevalent cases in the region at the end of 2005. 7

4.2 NEW CASE DETECTION There were 7201 new cases detected in 2005, corresponding to a new case detection rate of 0.413 per 100 000 population compared to 14 674 new cases detected in 1991 with a rate of 0.97 per 100 000 (Table 2); however, there is an increase by 14% as compared to the 2004 data. Four countries contributed 82% of all new cases detected, with the highest proportion of 44% of all new cases detected in the Philippines (Figure 2). FIGURE 2 Distribution of new cases of leprosy detected in 2005 The new case detection rate varied from 0 to 201.6 per 100 000 in 2005. Two countries have reported case detection rates of more than 10 per 100 000, with the highest in the Federated States of Micronesia. Another 11 countries and areas reported case detection rates between 1 and 10 per 100 000. Of the remaining 24 countries and areas, eight countries and areas reported case detection rates between 1 and 0.99 per 100 000; six countries and areas reported that no new cases were detected; and eight countries and areas have not sent in their reports (Figure 3). 8

FIGURE 3 New case detection rates per 100 000 population in 2005 Note: No cases were detected in Cook Islands, Mongolia, Niue, the Pitcairn Islands, Tokelau, Tonga, Tuvalu, Vanuatu, and Wallis and Futuna. Since 1991, when the region attained the elimination goal, there was a continuous decline in the new case detection rate up to 2004; however, a 14% increase was noted in 2005 (Figure 5 and Table 4). This increase was mostly due to an increased number of detected new cases in Kiribati, the Federated States of Micronesia, the Philippines, and Solomon Islands, following intensification of case detection activities. 9

New case detection includes patients who showed the onset of the disease during 2005 (incident cases) as well as in previous years (backlog cases that remained undetected). The exact proportion of the backlog cases among the new cases is not known. Case detection is also influenced by the intensity of programmed activities, service coverage, and the reporting system, as well as sensitivity and specificity of the diagnosis. Therefore, the new case detection rate may not represent the true incidence and degree of transmission of infection in the community. 4.3 PREVALENCE The prevalent cases decreased from 67 593 in 1991 to 9460 in 2005 and the prevalence rate dropped continuously from 0.45 per 10 000 to 54 per 10 000 in the same period, representing a decrease of 87.4%. The Lao People s Democratic Republic, Malaysia, and Viet Nam contributed largely to this latest reduction in the prevalence rate. Only two countries, China and The Philippines have reported more than 1000 registered cases in the region. When comparing rates, as in previous years, some small countries and areas (Kiribati, the Marshall Islands, and the Federated States of Micronesia) showed serious leprosy problems (Figure 4), though in absolute numbers their contribution to the regional disease burden was negligible. FIGURE 4 Distribution of registered cases and the prevalence rates per 10 000 for eight countries in the Western Pacific Region (2005) 10

4.4 OTHER INDICATORS 4.4.1 MB, CHILD, AND DISABILITY GRADE 2 PROPORTIONS AMONG NEW CASES Among new cases detected in 2005, the proportion of Multibacillary (MB), disability grade 2, and those children younger than 15 years, showed only marginal changes from 2004. The proportion of MB cases among new cases detected has an average of 73%, reaching a peak of 81% in 2005. The Philippines, with 94.3%, registered the highest MB proportion among new cases detected in 2005. This proportion indicates the magnitude of the potential source of transmission and risk for complications such as reactions and neuritis which, if not treated adequately, could lead to disabilities. China and the Philippines reported the highest number of new cases in 2005. Visible disability, expressed as grade 2, represented, on average, 13% with a range of 9% to 15%, between 1994 and 2005, with the lowest rate noted in 2005. The proportion was high in Cambodia, China, the Lao People s Democratic Republic, the Republic of Korea, Viet Nam, and a few other island countries and areas, indicating delay in detection or self-reporting of cases. The percentage of new cases involving children younger than 15 years was 7%, compared to a range of 3% 9% between 1994 and 2005 (Table 3). This perhaps indicates that recent transmission of infection was in general at a low level. However, Kiribati, the Marshall Islands, the Federated States of Micronesia, and Papua New Guinea have reported high proportions of children among new cases, due to active case findings, specifically a school survey conducted in 2005, and also may reflect high level of transmission, as these are still the countries and areas that have yet to attain the elimination goal. TABLE 3 Proportion of MB, disability grade 2, and children below 15 years among new cases (1994 2005) Year New cases* No. Multibacillary No. % Disability grade 2 No. % Children <15 No. % 1994 10 697 8545 80 1232 12 372 3 1995 11 906 8027 67 1822 15 582 5 1996 13 070 8650 66 1637 13 1132 7 1997 13 583 9385 69 2064 15 1076 8 1998 10 587 7216 68 1518 14 887 8 1999 9482 6714 71 1172 12 882 9 2000 8360 6300 75 1036 12 647 8 2001 7409 5708 77 890 12 519 7 2002 7187 5549 77 867 12 505 7 2003 6165 4871 79 701 11 430 7 2004 6195 4902 79 748 12 520 8 2005 7201 5815 81 673 9 520 7 Total 111 842 81 682 73 14 360 13 8072 7 *The numbers are those reported by the countries and areas in the year considered; countries that did not report were not included. 11

4.4.2 CASES CURED Information was not available for cases cured. The proportion of patients who complete their prescribed treatment regimen on time is a proxy indicator for cure rates based on cohort analysis, which is not incorporated in the annual report forms. 4.4.3 PREVALENCE/DETECTION RATIO On average, the ratio between prevalence and detection was 1.3 with a marginal decrease as compared to 2004. Twelve-month fixed duration MDT for MB cases was introduced in 1997-98, so the ratio should not exceed 1.5 for the countries and areas that introduced the one-year policy. The ratio was very high in the Republic of Korea (28.0) and high in Hong Kong (China) (8.0), Malaysia (2.9), China (1.9) and Singapore (1.9) (Table 1). This indicates that, in these countries and areas, patients are treated longer than necessary; registers are not updated or cleaned; patients are irregular in taking their treatment; or a combination of these factors. 4.5 POST-ELIMINATION TRENDS OF PREVALENCE AND NEW CASE DETECTION RATES 4.5.1 REGIONAL TRENDS The new case detection rate has varied from 0.97 in 1991 to 0.413 per 100 000 in 2005. The rate has generally remained stable up to 1997 with only small variations between years. A marked reduction of 23% occurred in 1998 and declined continuously until 2004. Analysis of data from 1991 to 2004 revealed a significant declining trend in the new case detection rate, reflecting interruption of transmission and effective programme coverage and implementation. In 2005, a 14% increase was recorded as compared to 2004, brought about by increasing detection activities and a leprosy awareness campaign in the Lao People s Democratic Republic, the Federated States of Micronesia, the Philippines, and Solomon Islands. Such increase in case detection rate is temporary or artificial and will taper down in succeeding years. The prevalence rate has varied from 0.45 per 10 000 in 1991 to 54 in 2005. The rate has declined continuously following elimination. The rate of decline has slowed down during the last six years. With the introduction of a single dose treatment regimen for single lesion and one-year duration for MB, the duration of the disease has been reduced to between 1 day and 12 months. As a result, prevalence is converging with detection. 12

TABLE 4 Trend of the prevalence and new case detection, Western Pacific Region (1991 2005) Year Regional Population (000s) Registered cases Newly detected cases Number Rate per 10 000 Number Rate per 100 000 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 1 515 579 1 537 199 1 560 521 1 580 357 1 610 291 1 628 600 1 634 465 1 652 781 1 672 418 1 706 434 1 694 691 1 706 168 1 729 924 1 743 620 1 752 283 67 593 42 254 35 145 38 733 30 556 26 275 23 370 19 076 14 195 12 731 11 764 11 035 10 449 10 000 9460 (0.45) (0.28) (0.23) (0.24) (0.19) (0.16) (0.15) (0.12) (9) (7) (69) (65) (6) (57) (54) 14 674 13 594 11 034 12 643 11 907 13 070 13 583 10 600 9494 8360 7409 7187 6165 6195 7201 (0.97) (0.89) (0.71) (0.81) (0.74) (0.80) (0.83) (0.64) (0.57) (0.49) (0.44) (0.42) (0.36) (0.356) (0.410 ) FIGURE 5 Trend of prevalence and new case detection rates (1991 2005) 4.5.2 TRENDS IN SOME COUNTRIES AND AREAS The prevalence and new cases detection trends in countries and areas with large populations showed a consistent and continuous decline after reaching the elimination target of prevalence rate of less than 1 per 10 000 (Figure 6 and Figure 7). However, there were wide fluctuations in countries and areas with small populations, sometime even crossing over the elimination level, especially in countries and areas with populations of less than 500 000 (Figure 8). These trends will be closely monitored and appropriate actions will be initiated to sustain elimination where necessary. 13

FIGURE 6 Trend of prevalence rates after elimination in some large countries FIGURE 7 Trend of new case detection rates after elimination in some large countries FIGURE 8 Trend of prevalence rates after elimination in some small countries and areas 14

5 PROGRAMME ACTIVITIES 5.1 STRENGTHENING NATIONAL PROGRAMMES The 11 countries and areas of Cambodia, China, Kiribati, the Lao People s Democratic Republic, the Marshall Islands, the Federated States of Micronesia, Papua New Guinea, the Philippines, Samoa, Solomon Islands, and Viet Nam, were provided with technical assistance to strengthen programme capability in planning and implementing special projects, programme review, and planning, training, and evaluation, between 1996 and 2005. They were the countries and areas that most benefited from special projects, especially Cambodia and the Philippines, which achieved elimination in 1998. Implementing the biregional strategy of sub-national approaches, integration into general health services, monitoring supervision and surveillance, and sustaining political commitment and partnership has started this year in Cambodia and Viet Nam, and plans were coordinated with the national programme managers for wider implantation in the coming years. 5.2 SPECIAL PROJECTS LEC AND SAPEL In 2005, the WHO Regional Office for the Western Pacific focused its efforts on health education campaigns and rapid surveys of endemic pockets and screening of selected populations in Cambodia, Kiribati, the Federated States of Micronesia, the Philippines, and Solomon Islands that resulted in the detection of 330 new cases. These countries and areas, with the assistance of WHO and nongovernmental organizations (NGOs), and through their own resources, developed and implemented LECs and SAPELs. The first such projects were implemented in 1996; by 2004, 86 projects have been completed, covering 42 million people and detecting 5208 new cases. The figures represented 7% of the cumulative new cases detected in the region during these nine years. The countries and areas that most benefited from these projects were Cambodia and the Philippines, giving coverage of 97% and 26%, respectively, of their total populations. 15

5.3 OTHER SPECIAL PROJECTS Kiribati, the Marshall Islands, and the Federated States of Micronesia, which had high prevalence rates, implemented special projects between 1996 and 2000 to accelerate and achieve the elimination goal. The projects consisted of total or selected population surveys and administration of preventive therapy, consisting of Rifampicin-Ofloxacin-Minocycline (ROM) combination for adults and rifampicin alone for children younger than 15 years once or twice at yearly intervals to all healthy people during screening in Kiribati and in the Federated States of Micronesia, and family contacts of cases in the Marshall Islands. During screening, a large number of new cases were detected and treated with MDT. After an initial rise, both prevalence and case detection rates declined following implementation of the projects in all three countries and areas. In addition to conducting orientation training workshops on the elimination of leprosy, and case detection in endemic pockets, information, education, and communication activities (IEC) were intensified in all the three countries and areas in 2002 and followed up with the launching of national leprosy awareness campaigns. In the Federated States of Micronesia, screening of 16 123 children in schools, 448 family contacts of cases, and 5344 populations in high endemic villages have resulted in detection of 44 new cases in 2005. 5.4 POST-ELIMINATION SURVEILLANCE SYSTEM The guidelines for the post-elimination surveillance system were developed in 1991 in the WHO Regional Office for the Western Pacific. The system was based on establishment referral centres for case diagnosis and management, referral of suspected cases from the periphery, notification of individual cases to the central level, mapping of the notified cases, integration of leprosy information into the general health information system, sustaining leprosy awareness in the community, and general health staff and evaluation. A pilot project of post-elimination surveillance system was started in selected provinces of Cambodia in 2000 and extended to cover all provinces by 2004 following periodic evaluation. The pilot projects that were started in 2001 in selected provinces of the Lao People s Democratic Republic and Viet Nam were continued. The geographic information system (GIS) developed in Cambodia and Viet Nam is being utilized in identification of endemic pockets at the peripheral level. The concept, guidelines, and activities of the post-elimination surveillance are included as strong pillars in the biregional strategy, which is now being implemented. 16

5.5 COLLABORATION WITH OTHER PARTNERS Continuous collaboration has been maintained with Sasakawa Memorial Health Foundation (SMHF), which funded the activities implemented in Cambodia, the Federated States of Micronesia, and Papua New Guinea. Likewise, a partnership programme with the Pacific Leprosy Foundation has been strengthened, assisting south Pacific countries and areas, especially Kiribati, Samoa, Solomon Islands, Tonga, and Vanuatu. Coordination meetings with governments and NGOs for leprosy elimination were held in Cambodia, China, the Lao People s Democratic Republic, the Philippines and Viet Nam. 17

6 ISSUES AND CHALLENGES (a) (b) (c) (d) (e) (f) Achieving the goal of elimination of leprosy as a public health problem in the remaining countries of Kiribati, the Marshall Islands, and the Federated States of Micronesia in the coming years. In some countries and areas, accessibility is restricted because of the poor communications and vast distances (small islands countries and areas, for instance). In others (such as Papua New Guinea and the Philippines), some places are inaccessible because of security concerns. Therefore, patients living in difficult-to-reach places now represent an important proportion of the total caseload and it will be harder to detect these patients. Few countries and areas (China, Hong Kong [China], Malaysia, the Republic of Korea, and Singapore) still have a prevalence and detection ratio higher than 1.5, indicating that patients are treated longer than necessary and that they are inflating the prevalence. Moreover, the implementation of the 12-month duration regimen for MB is progressing slowly in certain areas. Countries and areas such as Cambodia and the Lao People s Democratic Republic, which reached elimination by 1998, are still dependent to a large extent on external resources in running their programmes to sustain elimination. There are a large number of patients who were declared cured but require care after cure for the treatment of complications such as reactions and plantar ulcers. Similarly, there is a large number of cured cases who need physical and socio-economic rehabilitation because of disabilities developed from the disease. The recognition and management of post-mdt reactions and the progressions of leprosy disabilities affects the quality of life and social re-integration of patients. The epidemiology of the disease itself is still a challenge. To date, there is no effective way to measure the level of infection and incidence of the disease in the community. This is complicated by very long incubation period of the disease and the process of self-healing of many single lesions, as well as the tendency for the patients to hide the disease because of social stigma. 18

(g) (h) (i) (j) There is a fast-turnover of skilled or trained staff at the peripheral level, which poses difficulties in ensuring wider coverage of leprosy services in currently underserved population groups and in continuing and sustaining quality leprosy services in some countries and areas. Strengthening integration of leprosy services into the general health services through capability building is needed to ensure quality diagnosis, treatment, and management of complications, particularly in previously endemic countries and areas. Sustained political commitment and adequate resources from national governments is needed; partnerships and collaboration with NGOS are needed to pursue quality leprosy control activities, further reduce the disease burden, and support socio-economic rehabilitation. Continuing public awareness is needed through sustained advocacy and IEC activities. Early self-reporting of cases in the community can be promoted by spreading awareness that leprosy is a curable disease with MDT drugs that are available safe and free at health centres; further, IEC activities should emphasize that social stigma and discrimination of people affected with leprosy has no place in the society today. 19

7 FUTURE PRIORITIES AND ACTIVITIES 7.1 COUNTRIES AND AREAS IN WHICH LEPROSY HAS NOT BEEN ELIMINATED (1% OF THE REGIONAL POPULATION) The trend of the prevalence rates for the last 10 years in the Marshall Islands and in the Federated States of Micronesia has declined after an initial rise due to special projects implementation (Figure 9). However, it stagnated for the last few years. Due to high baseline endemicity, the long incubation period of the disease, and other environmental and socio-economic factors, the disease may have persisted, and needs more time for reaching elimination, as compared to other countries and areas. These two countries and areas will be further supported to continue elimination activities, including screening of high-endemic pockets, training, IEC, and strengthening of technical and managerial skills, particularly on integration and research. The progress towards attaining the elimination goal will be closely monitored and supervised. FIGURE 9 Trend of prevalence rates in two countries that have not yet achieved the elimination target in the Western Pacific Region 20

7.2 COUNTRIES AND AREAS THAT ACHIEVED ELIMINATION AT THE NATIONAL LEVEL 7.2.1 IMPLEMENTATION OF THE BIREGIONAL STRATEGY TO SUSTAIN LEPROSY SERVICES FOLLOWING ELIMINATION The strategy document was sent to the national governments for their adoption, followed by an extension of technical support for development of country-specific action plans for implementation of the strategy, focusing on total integration of leprosy services with general health services. Countries and areas will be prioritized based on situation analysis with reference to elements of the strategy and the number of cases being reported. Strategy implementation was piloted initially in two countries and areas (Cambodia and Viet Nam) in 2005 and preparation is underway to implement it in China, Papua New Guinea, and the Philippines. Advocacy to sustain political commitment and partner support was pursued vigorously for the required resources. 7.2.2 VALIDATION OF LEPROSY ELIMINATION Validation or certification of elimination is not done, since cost-effective and practical tools are not readily available. However, periodic independent external assessment using Leprosy Elimination Monitoring (LEM) protocol will help to evaluate the programme performance. Efforts will be made to review the LEM document for its adaptation to suit low and very low prevalent situations and apply the same to validate programme achievements, particularly identifying main indicators for monitoring progress and status of leprosy control activities under low endemicity. 21

8 RESOURCE REQUIREMENTS To carry out the leprosy strategic plan, US$ 300 000 in external assistance is required annually for the coming few years. Furthermore, assistance provided by NGOs to national governments should be kept at current levels, particularly as the newly-developed strategy to sustain quality leprosy services is introduced and implemented in all countries and areas, toward a functional and complete integration of leprosy control activities into general health services. 22

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