In the post-elimination era, guarding against complacency is critical.
The achievements recorded under the WHO's leprosy elimination strategy have been heralded as a public health success story. The challenge now is to ensure that these achievements are not reversed in the "post-elimination" era.
In a presentation at the 17th International Leprosy Congress, Professor Cairns Smith of the University of Aberdeen and a member of the technical commission of the International Federation of Anti-Leprosy Associations (ILEP), compared the WHO strategy that was used to achieve the elimination goal with the current strategy to further reduce the leprosy burden and sustain the quality of leprosy services.
In many ways, he said, the content of the two strategies is the same in terms of their activities, but the current strategy is being delivered in a different context in which the prevalence of the disease is low. "One of the key concepts (of the new strategy) is sustainability."
In the elimination era, the main thrust involved case detection and treatment using multidrug therapy (MDT). To achieve the elimination target of under 1 case per 10,000 population, a number of simplifications were introduced to make the program easier to deliver in the field. In case detection, smears were no longer essential to diagnose the disease, and experts were not necessary to classify leprosy cases as either paucibacilliary or multibacilliary.
Treatment with MDT evolved, becoming shorter and fixed in duration. The introduction of blister packs made it easy for the drugs to be distributed and easy for patients to take, and MDT was also available free of charge.
The strengths of the elimination strategy were its focus and the fact it was time-bound: there was a specific target, and there was a given period in which to achieve the goal.
But by its very nature, the elimination strategy was unsustainable, he said. It consisted of many vertical components, with dedicated staff at all levels, separate recording and reporting systems, its own drug distribution system and substantial funding devoted to the goal of elimination.
"The issue of sustainability is important," said Professor Smith, "because although the prevalence of leprosy fell dramatically during the elimination strategy, the same did not happen with new case detection, which remained remarkably stable over that period."
The strategy for 2006-2010 is designed to address this issue. It is delivered in an integrated context, is oriented toward continuing to reduce the burden of leprosy, and is no longer time bound.
It is a strategy that emphasizes quality and accessible services at the local and referral level, makes human rights and participation by those affected an essential component, and tackles both the physical and social consequences of the disease. "We are dealing with leprosy not just as a disease that requires MDT," Professor Smith said.
Quality has to be defined by the patient. The program must be patient-centered.
As to just what "quality leprosy services" entail, they comprise services that are accessible to all who need them, with no geographical, economic or gender barriers, he said. "Quality has to be defined by the patient, and hence the program is referred to as patient-centered."
Included are every aspect of case management- diagnosis, treatment, management of reactions, prevention of disability, referral for complications and rehabilitation as well as skill transfer for self-care.
Unfortunately, said Professor Smith, the evidence suggests that accessible and quality leprosy services are not being sustained. Different regions are doing different things. "I think one of the big challenges facing us at the moment is complacency. Having achieved elimination, we are behaving as if we have won a war, when we have only won a battle."
The problem now, and the challenge for the future, is to implement the strategy, he said. To this end, operational guidelines have been produced and a training program for national program managers is now being rolled out. "Partnership is a fundamental focus of the new strategy," he said. "We cannot do this on our own, as one group or sector. WHO, ILEP, patients, families have to come together to address the challenge of making national programs sustainable."