Mycobacterium leprae--millennium resistant! Leprosy control on the threshold of a new era.

Over the past decades, the conditions of leprosy control implementation have changed dramatically. Introduction of multidrug therapy, together with the global effort of the World Health Organization to eliminate leprosy as a public health problem, had a tremendous impact on leprosy control, particularly by decreasing the registered prevalence of the disease. At the beginning of the new millennium, leprosy control programmes face several new challenges. These relate not only to changes in the prevalence of the disease, but also to changes in the context of leprosy control, such as those created by health sector reforms and other disease control programmes. This review discusses current knowledge on the epidemiology of Mycobacterium leprae and some important aspects of leprosy control. It is argued that our understanding is still insufficient and that, so far, no consistent evidence exists that the transmission of leprosy has been substantially reduced. Sustainable leprosy control, rather than elimination, should be our goal for the foreseeable future, which also includes care for patients on treatment and for those released from treatment. This, however, requires new strategies.

Cultural meanings of tuberculosis in Aceh Province, Sumatra.

This paper shows how disease transmission and particularly what biomedicine calls tuberculosis are interpreted in the non-Western context of Aceh Province, Sumatra, Indonesia. It tries also to focus on factors influencing perceptions and health-seeking behaviors. Results show that what biomedicine calls TB is represented by a semantic network of illnesses. Parts of this network are clearly identified as transmissible while others are related to specific phenomena affecting the individual, such as terbuk (poisoning) or trouk (fatigue produced by hard work), and are not considered contagious. Forms of transmission are interpreted mostly through empirical and analogic categories. TB is attributed to four different aspects: (a) biomedical categories such as germ theory; (b) socio-economic conditions; (c) transgression of social rules; and (d) poisoning and the influences of supernatural powers. Health-seeking behaviors are related to the perceived causes of the disease, economic factors, and the accessibility of health services.

Health systems research in leprosy control--what contributions can it make?

The paper describes a Health Systems Research (HSR) training programme which took place at the All Africa Leprosy, Tuberculosis and Rehabilitation Training Centre (ALERT) in Ethiopia. The training consisted of three stages: an initial workshop focussing on protocol development, followed by a fieldwork period and a data analysis and report writing workshop. Twenty participants, divided over four groups, took part in the training and carried out the research alongside their day-to-day professional commitments. Three of the projects were concerned with prevention of disabilities, one with integration of the leprosy programme into the general health services. Based on the findings of their research, each group produced a set of recommendations and a plan of action for the implementation of these recommendations. The contribution of HSR to leprosy control is discussed.

Prevention of impairment in leprosy; results from a collaborative project in China.

OBJECTIVE: to evaluate programs of prevention and treatment of impairments due to leprosy in 8 geographical areas in the People's Republic of China. DESIGN: follow up of cohorts of leprosy patients receiving a range of different interventions. SETTING: 8 different geographical areas in China, varying in urban and rural characteristics from 6 provinces and 2 municipalities. SUBJECTS: leprosy patients who were receiving or had completed a course of antileprosy chemotherapy. INTERVENTIONS: a range of interventions, including steroids, self-care training, adapted footwear, surgery and provision of prostheses. MAIN OUTCOME MEASURES: changes in eye, hand and foot impairments between baseline assessment and assessment at 2 years. RESULTS: 232 out of 3571 patients assessed monthly over 2 years developed acute neuritis and, in most areas, were promptly and adequately treated. Regular self care of eyes was established in 238 out of 313 patients with lagophthalmos and was associated with reduction in the prevalence of conjunctivitis. Regular self care of hands was established in 730 out of 1010 patients with neurological impairment of the hand; this was associated with a reduction (80%) in hand cracks and wounds. Regular self care of feet was established in 745 out of 1094 patients with neurological impairment of the feet; this was associated with a 83% reduction in patients with cracks and a 33% reduction in patients with sole wounds. A footwear program was established in all 8 areas providing footwear to 4698 patients over the 2-year period; this was associated with a reduction of 61% and 21% in patients with cracks and wounds, respectively. Management of complicated sole wounds in 256 patients resulted in 69% of these patients being free of sole wounds at 2 years. Targets for reconstructive surgery and amputations were not fully attained, but lower limb prostheses were provided for 306 patients. CONCLUSIONS: leprosy is a chronic disease characterized by peripheral neuropathies which can result in increasing secondary impairments and disabilities. The emphasis, in countries such as China where the chemotherapy programs have been effectively implemented, is shifting to prevention and treatment of impairments. This innovative program in China has successfully demonstrated that it is possible to prevent and reverse impairments due to leprosy.

Leprosy control in 7 districts of south Sulawesi, Indonesia, 1986-91.

This paper describes the leprosy control programme in 7 districts of the South Sulawesi Province in Indonesia. This province is reported to have the highest prevalence of leprosy in the country. The programme started in 1986 with re-registration of all patients on the cumulative registers. Strict criteria for admission of patients to MDT were initially applied. In 1990 it appeared that these criteria had been too strict, thus necessitating a second re-registration of patients still on DDS monotherapy. More flexible criteria for admission to MDT led to an increase in MDT coverage from 45% to 78% within 6 months. By April 1991, 5 years after the start of the programme, the registered prevalence had decreased from 4.4 per 1000 in 1986 to 1.6 per 1000; the coverage with MDT had increased from 6% in 1986 to 78%, and the case detection rate remained stable around 4 per 10,000 after an initial increase at the start of the programme.

A new focus of Schistosoma mansoni in the western province of Zambia.

A new focus of Schistosoma mansoni in the Western Province of Zambia is described. Four study groups were investigated using the Kato faecal smear method. Prevalence ranged form 2-38%, intensity of infection ranged from 0-4920 eggs per gram faeces.