The Goodwill Ambassador travels to the country with the highest percentage of child cases of leprosy, and revisits Mozambique to assess the situation 10 years after it achieved the elimination of leprosy as a public health problem.
|A view of Mutsamudu, the capital of Anjouan, the most densely populated of the three islands that comprise the Union of Comoros|
Located in the Indian Ocean between Mozambique and the northern tip of Madagascar, the Union of Comoros consists of three islands with a total population of around 850,000. A fourth island, Mayotte, remains under French administration after it chose not to join Grand Comoros, Anjouan and Moheli in forming an independent state in 1975.
Comoros is the only country among the 47 overseen by the WHO’s Africa Regional Office (WHO AFRO) where the prevalence rate of leprosy is above 1 case per 10,000 population. It also has the highest percentage of child cases in the world, approaching 40% of new cases. This was my first visit, and I wanted to find out what was holding Comoros back.
Of the three islands, Anjouan is highly endemic for leprosy. During the French colonial period, it served as a leprosarium. Some theorize that this may have made the present-day population genetically more susceptible to the disease. But there are other factors at work, too. Anjouan is poor, densely populated and children suffer from malnutrition, all factors creating favorable conditions for transmission.
Dr. Alexander Tiendrebeogo, the WHO focal person for leprosy in Africa, added a further detail, telling me that Comoros was very late in taking up the WHO’s recommended treatment regimen for leprosy using multidrug therapy (MDT). The WHO first recommended MDT in 1981, but it wasn’t introduced to Comoros until 2001—20 years later.
In the interim, a team from the Institute of Tropical Medicine, Antwerp, conducted research using a single-dose treatment for paucibacillary (PB) leprosy and a six-week course of treatment for multibacilliary (MB) leprosy cases—compared with the recommended regimen of six months’ MDT for PB cases and 12 months for MB cases. By 2000, this had led to a high rate of relapses.
Having belatedly introduced the prescribed MDT regimen from 2001, Comoros achieved the leprosy elimination target of reducing prevalence to below 1 case per 10,000 population; however, it was not able to sustain this after 2007.
A closer look at the figures puts the issue in sharp relief. In 2017, Comoros recorded 429 new cases of leprosy, making for a prevalence rate of 4.58 per 10,000; this compares with 0.22 for the WHO AFRO region as a whole. The new case detection rate was 51.80 per 100,000 population, compared with 0.20 for WHO AFRO.
By island, Grand Comoros accounted for 2 cases, Moheli 58 and Anjouan 369. There were 164 child cases, of which Anjouan contributed144.
While the rate of child cases is very high by WHO AFRO standards—over 38% versus 10% for the region—by contrast the rate of Grade 2 disability at time of diagnosis is only 2%, compared with around 14% for the region, indicating that cases are being diagnosed early.
My visit began on the main island, Grand Comoros, where I called on Minister of Health, Solidarity and Gender Promotion Dr. Rashid Mohamed Mbarak Fatma. The next day I traveled to Anjouan, accompanied by the health minister and other officials.
One of my first tasks was to pay a courtesy call on Governor Dr. Abdou Salami Abdou to explain my mission. I expressed concern about the high rate of child cases and requested that he use his position to speak out about leprosy so that awareness reaches every corner of society. The governor drew my attention to the fact that Anjouan is the poorest island in the union, underlining the broader context in which Anjouan’s leprosy problems must be viewed. “We need to improve the condition of the people,” he told me.
That afternoon I attended a meeting of government officials, partners and experts to discuss the situation on the island. It was clear that despite the efforts of the country’s leprosy program, which is supported by its international partner Action Damien, there are insufficient human and material resources to cover the island in a timely fashion.
Mini case-detection campaigns have had some success over the years, but they have only taken place occasionally and reach only some of Anjouan’s communities. There is also no organized effort involving persons affected by leprosy that could assist in case finding.
|Checking supplies of MDT at Hombo Hospital|
I visited Hombo Hospital, where the doctors, health workers and Action Damien members tackling leprosy are based. While there, I met a number of outpatients undergoing treatment with MDT. They included a girl whose symptoms had been spotted by another patient; a pair of brothers—the older of whom had identified signs of leprosy in his sibling as a result of his own experience of the disease; and a girl who was diagnosed by follow-up screening after a case was found in her village.
|Posing with two siblings (to my left and right) under treatment, together with their mother and another young patient|
Showing the power of the media, reports of my visit had prompted an anxious mother to bring her daughter to the hospital for a checkup, although it turned out that the blemish on the young woman’s skin was not leprosy.
From the hospital, I traveled 75 minutes through lush tropical rain forest to visit a clinic in Mahale, a community of some 10,000 people in the northeast of the island. It had already seen around new 10 cases this year by the time of my visit, including a first-year university student and a 65-year-old man already disabled by the disease. Based on the figures for this one village alone, I could get a feel for the extent of the challenge on Anjouan.
Dr. Rashid, the health minister, told me that Comoros aims to reduce the country’s prevalence rate to below 1 by 2030 and that her ministry is working on plans to bolster the leprosy control program. Later, when I paid a courtesy call on President Azali Assoumani, he suggested a more ambitious target of 2025 and I hope this will be pursued.
As always, I took the opportunity of press conferences on Anjouan and Grand Comoros to enlist the support of the media, telling them their role in helping to reduce the number of patients is extremely important. “By taking an interest in this issue, you can make a huge difference,” I said, calling on them in their reporting to encourage families to conduct skin checks for tell-tale signs of the disease.
I left Comoros with the feeling that activities on Anjouan need to be scaled up so that every village is covered. If every health facility is adequately trained to diagnose and treat leprosy, and if people affected by leprosy and others in the community can become more involved in identifying cases and referring them to health workers, this will help to increase the detection rate.
Comoros faces many challenges, but I hope that the government will draw encouragement from the example of other African countries that it is possible to tackle leprosy effectively. With political will from the top and greater involvement of the community as part of the solution, it can be done.
From the Union of Comoros I traveled to Mozambique. My last visit was in 2008, the year that this southern African nation achieved elimination of leprosy as a public health problem.
Unfortunately, Mozambique did not sustain its efforts against leprosy as its health priorities shifted elsewhere, and the number of cases began to increase. Compounding the situation, the previous national leprosy control manager was not immediately replaced after he retired.
However, under the current program manager, Dr. Francisco Guilengue (see sidebar), the government is recommitting itself to anti-leprosy activities, assisted by funding from the Bangkok Declaration Special Fund (BDSF).*
|Addressing a leprosy awareness rally in Nampula Province|
The good news is that Mozambique is still below the elimination threshold of 1 case per 10,000 population at the national level, although this is not the case in the north of the country, where three provinces—Nampula, Cabo Delgado and Zambezia—contribute 90% of new cases.
|With Mozambique Health Minister Dr. Nazira Abdula in Maputo|
Before heading north to visit Nampula Province, I called on Health Minister Dr. Nazira Abdula in the capital, Maputo. I was pleased to receive from her a firm commitment to strengthen the program in light of the current situation—a situation made clear in a presentation by Dr. Guilengue.
In 2015, the year he was appointed national program manager, there were 1,335 new cases of leprosy; in 2016, new cases increased to 1,681; and in 2017, they rose to 1,926. Over the same period, the number of endemic districts in the country increased from 23 to 44. Furthermore, in the first six months of 2018, 951 new cases have been registered nationwide, compared to 684 in first six months of 2017.
As Dr. Guiengue explained, the increase in numbers is due to actions taken as a result of support from the BDSF to target highly endemic districts. These include mini campaigns, promoting village leprosy days in remote areas, and involving self-care groups of persons affected by leprosy in active case finding. The program is also implementing a shift from paper to electronic record-keeping so that health workers have easy access to data via tablets and PCs.
But challenges remain: insufficient funding; the emergence of additional hotspots; poor knowledge of leprosy in many communities that results in delayed diagnosis and discrimination; medical personnel in endemic areas not adequately trained in leprosy; and lack of transport in endemic districts for active case finding and community visits.
Arriving in Nampula Province, I had a meeting with Governor Victor Borges, followed by a briefing at the provincial health department. There I learned that as a result of the increased activities of the program, there had been a 48% increase in cases in the province in the first six months of 2018 over the same period last year, up from 374 cases to 553. It now has the most cases of leprosy in the country.
|Crowds welcome the Goodwill Ambassador to Namaita village|
Next I set out for Namaita, a village in the district of Rapale, to attend a rally promoting leprosy awareness. Around 800 people had gathered from Namaita and neighboring communities for an event that featured speeches, singing and dancing. Among those present were a group of persons affected by leprosy who told me they were grateful for the treatment they received but that more drugs were needed as there were still many cases of leprosy in the area.
When I spoke, I urged the crowd to check their families for any patches on the skin and go and have them examined by a health worker if they found anything suspicious. “Don’t hesitate to seek treatment. It’s free,” I told them. This was a theme I repeated later in the day during a live interview I gave to Radio Haq, an Islamic radio station, before leaving Nampula.
|Posing with health volunteers|
Back in Maputo, I continued my media work with another interview, this time for national television network TVM. The program was due to be dubbed into over a dozen local languages.
Resolving the issue of leprosy must involve the whole of society; it is not just an issue for doctors and patients. Politicians, school teachers, religious leaders and the media all need to be part of the solution. That said, it is important that the health ministry is firmly behind anti-leprosy efforts: therefore, I am grateful to Health Minister Dr. Abdula for the commitment she gave me during my visit and for the work now being undertaken by the program under Dr. Guilengue.
* The Bangkok Declaration was issued in July 2013 following an international leprosy summit, with global experts and health ministers of endemic countries reaffirming their commitment to a leprosy-free world. The Nippon Foundation established a special fund following the summit to be used for early case finding and treatment in endemic countries.