Estratificación epidemiológica de enfermedades seleccionadas. Granma. 2018 / Epidemiological stratification of selected diseases. Granma. 2018

La estratificación es una estrategia útil para obtener un diagnóstico objetivo de acuerdo con el cual planificar las actividades de prevención y control de las distintas enfermedades. El objetivo fundamental del trabajo fue identificar el comportamiento territorial del riesgo absoluto de enfermedades transmisibles seleccionadas en la provincia. Se realizó la estratificación epidemiológica de 5 enfermedades seleccionadas (EDA, IRA, Tuberculosis, Meningoencefalitis viral y Lepra), utilizando para ello el método de riesgo absoluto, que consistió en la formación de diferentes estratos de riesgo: bajo, mediano y alto. Durante el año 2018 se clasificó como municipio de alto riesgo Bayamo; la distribución por municipios según número de entidades en alto riesgo pudimos constatar lo siguiente: Bayamo (5); Manzanillo (3); Cauto Cristo, Yara, Campechuela, Media Luna, Niquero, Buey Arriba y Guisa (2 cada uno); Jiguaní, Pilón y Bartolomé Masó (1 cada uno); Río Cauto (no se encuentra en alto riesgo para ninguna entidad); según las enfermedades seleccionadas, la distribución de los municipios que se encontraban en alto riesgo fue la siguiente: IRA, Tuberculosis, Meningoencefalitis viral y Lepra (4 municipios en cada una), EDA (3 municipios). La conformación de los estratos de riesgo según la metodología escogida garantiza a los jefes de programa el diseño de estrategias de intervención para cada una de las enfermedades analizadas, según el comportamiento de los factores asociados a las mismas y completar el proceso de diagnóstico-intervención-evaluación(AU)

Stratification is a useful strategy to obtain an objective diagnosis according to which to plan prevention and control activities for different diseases. The main objective of the work was to identify the territorial behavior of the absolute risk of selected communicable diseases in the province. Epidemiological stratification of 5 selected diseases (EDA, ARI, Tuberculosis, Viral Meningoencephalitis and Leprosy) was carried out, using the absolute risk method, which consisted of the formation of different risk strata: low, medium and high. During 2018 Bayamo was classified as a high risk municipality; the distribution by municipalities according to the number of high risk entities we could verify the following: Bayamo (5); Manzanillo (3); Cauto Cristo, Yara,Campechuela, Media Luna, Niquero, Buey Arriba and Guisa (2 each); Jiguaní, Pilón and Bartolomé Masó (1 each); Río Cauto (it is not at high risk for any entity); According to the selected diseases, the distribution of the municipalities that were at high risk was as follows: ARF, Tuberculosis, Viral Meningoencephalitis and Leprosy (4 municipalities in each), EDA (3 municipalities). The conformation of the risk strata according to the chosen methodology guarantees the program managers the design of intervention strategies for each one of the analyzed diseases, according to the behavior of the factors associated with them and completing the diagnostic-intervention process-evaluation(EU)

[Dramatic achievements in infectious disease prevention and treatment in China during the past 70 years].

At the beginning of the founding of People's Republic of China, infectious diseases, such as smallpox, plague, cholera, dysentery, typhoid, measles, diphtheria, pertussis, meningitis, mumps, schistosomiasis, Kala Azar, hemorrhagic fever, leptospirosis, encephalitis B, typhus, malaria, Kala Azar, leprosy, scarlet fever and pinkeye, remained as epidemic in the country and endangered people's health. During the past 70 years, the Chinese government spent huge efforts in infectious disease prevention and treatment by promulgating and implementing series of relative policies, laws and strategies, and also encouraged all Chinese people to participate in. The achievements of these efforts in controlling infectious disease epidemic were extremely successful. Today, the outbreaks and epidemic of infectious diseases in China were rarely happened with the rapid decreases in incidence and mortality rates of all notifiable infectious diseases. Smallpox was eradicated, and polio, filariasis, leprosy and neonatal tetanus were nearly eradicated. In addition, the incidence rates of vaccine-preventable diseases, i.e. measles, diphtheria, pertussis, meningitis, encephalitis B, hepatitis A, mumps, rubella, tuberculosis, were dramatically decreased and remained at relatively low levels for years. The incidence and prevalence rates of hepatitis B infection in Children decreased significantly and reached the phase objectives. Moreover, incidence rates of natural iatrogenic infectious diseases, i.e. diarrhea, typhoid and other intestinal infectious diseases, leptospirosis and schistosomiasis, and vectorborne diseases, i.e. typhus, malaria, Kala Azar, reached the lowest and some even closed to be eliminated in China. In general, infectious diseases dropped to the tenth from the top one leading cause of all deaths, which means that the achievement of Chinese infectious disease prevention and treatment strategies contributed tremendously in improving Chinese people's health status and life expectancy.

Políticas públicas referentes às incapacidades físicas em hanseníase na virada do século: uma década de (des)controle? / Public Policies related to Leprosy Physical Disabilities at the turn of the century: a decade of (lack of) control ?

Resumo Objetivos: Focando na década da virada do século, recuperam-se as principais diretivas das políticas públicas setoriais referentes ao controle das incapacidades físicas em hanseníase (IFH). Material e métodos: Procede-se à revisão expositivo-crítica das respectivas normas técnicas a partir das menções às mesmas nos textos oficiais da Organização Mundial da Saúde e do Ministério da Saúde do Brasil, publicados de 1995 a 2005. Resultados: Constata-se que as IFH são consideradas em plano secundário, essencialmente em função do tratamento medicamentoso eleito como estratégia prioritária para a luta contra a endemia. Conclusões: Conclui-se que, de equívoco em equívoco, específicos para as IFH e gerais para a doença, frustraram-se até os dias atuais por repetidas vezes, sobretudo em nosso país, expectativas institucionais relativas à eliminação da moléstia.

Abstract Objectives: The Public Policies referred to the control of the physical disabilities in leprosy (PDL) during the 1995-2005 decade are our main interest. Material and Methods: Wide-ranging thematic revision on official texts of the World Health Organization and of the Brazilian Ministry of Health, published during the mentioned period. Results: We have been able to aim evidences which pointed to the consideration that Public Policies related to the PDL are issued on a secondary level, essentially in function of the drug treatment, considered as priority against the endemic disease. Conclusions: We may conclude that, due to mistakes done specifically to the PDL and in general to the illness itself, commitments referring to the elimination of the leprosy were frustrate repeated times, unfortunately, mainly in our country.

Trends and patterns in leprosy in nine states of the Republic of the Sudan 7 years after the introduction of routine contact screening.

Background: This paper analyzes the trends of key indicators reflecting the epidemiological situation of leprosy in nine different states of the Republic of the Sudan after the introduction of a systematic contact screening in 2010. Methods: The routinely assessed data from the leprosy control program from 2010 to 2016 were analyzed. Results: Despite, intense contact screening, the overall number of new cases detected showed a decreasing trend. The female:male ratio among new cases was constantly low. The overall average number of contacts needed to screen in order to detect a new case among contacts was 64. However, this number varied significantly in the nine states under investigation, with the best yield being observed in the state with the lowest case detection rate. Conclusions: The total number of new cases of leprosy in nine states of the Republic of the Sudan has shown declining tendencies since 2010. Our data are not suggestive of a significant impact of contact screening on the trends of leprosy key indicators. Overall, contact screening proved to be efficient in most states, including those that exhibited very low annual new case detection rates (ANCDRs). Sensitization of personnel undergoing training and measures improving access of females to leprosy services are urgently needed.

Lepra en Colombia: ¿Se encuentra en la fase de post-eliminación? / No disponible

Hace más de diez años que la lepra en Colombia no se considera un problema de salud pública, ya que la prevalencia es menor de 1/10.000. Si embargo, los informes de 2012 correspondientes a 11 de 27 Departamentos (48%) revelan incidencias de 0.12 a 4.73 casos por 100.000 habitantes. El Ministerio de Sanidad y el Instituto de Salud dirigen y organizan el Programa Nacional de la Lepra (PNL), que planifica las actividades de prevención, vigilancia y control a nivel nacional. La logística está delegada a nivel regional (municipios, distritos, Departamentos), sin embargo en muchas zonas la deficiente estructura hospitalaria, los elevados costes, la falta de personal sanitario formado, o el difícil acceso a los servicios sanitarios son algunas de las barreras que impiden el desarrollo y acceso a las actividades que el PNL publica en sus guías. Lo mencionado anteriormente tiene como consecuencia un diagnóstico tardío con un 30% de discapacidades (grado 1 y 2) en el momento del diagnóstico. Tampoco hay una gran percepción de la enfermedad en la población general ni en los profesionales sanitarios sobre la incidencia de la lepra en Colombia. Esta es una revisión de la situación de la lepra en Colombia, teniendo en cuenta no solamente los datos estadísticos, sino también algunos aspectos que influyen en el diagnóstico tardío y la discapacidad hallados en pacientes en el momento de su diagnóstico. Esta revisión contiene opiniones personales del autor que pueden diferir de las de otros

Leprosy in Colombia is not considering as a public health problem since a prevalence rate less tan 1/10000 was achieved more than ten years ago. Nevertheless, reports of 2012 from 11 of 27 departments 848%) showed incidence rates from 0.12 to 4.73 cases per 100000 inhabitants. The Ministry of Health and the National Institute of Health directs and organize the National Leprosy Program ( NLP), which plan the activities for prevention, surveillance and control at national level. The operational activities are delegated to the regional levels (municipalities, districts departments) however in many areas poor hospital infrastructure, high costs, lack of health personnel trained, difficult access to the health services are some of the barriers that impede the development and access to the activities that the NLP publishes in guides. The above mentioned facts have as consequence late case detection with 30% of disability rates (grade 1 and 2) at the time of diagnosis. Also, there is not awareness in general population neither in health professionals about the existence of leprosy cases in Colombia. This is a review of the situation of leprosy in Colombia, taking into account not only statistical data, but also some aspects that influence late diagnosis and disability found in patients at the time of diagnosis. In this review may appear author's personal perceptions that may differ from others

Análisis de los nuevos casos de lepra detectados en la gobernación de Sohag, Alto Egipto, 2004-2008 / No disponible

Introducción: La lepra es una enfermedad crónica y compleja; el indicador de nuevos casos detectados es mejor que el de prevalencia para analizar la tendencia de la enfermedad. Este estudio analiza el patrón de nuevos casos de lepra, desde 2004 a 2008, en la gobernación de Sohag, Alto Egipto. Pacientes y métodos: Los datos referentes a nuevos casos diagnosticados de lepra se obtuvieron del hospital para la enfermedad de Hansen de Sohag, principal centro de referencia en la gobernación. Los índices de detección (CDR) se calcularon para cada año dividiendo los nuevos casos diagnosticados por la población media anual de cada año. Resultados: Fueron diagnosticados 587 pacientes entre 2004 y 2008. La edad media de los pacientes diagnosticados fue de 34 años, siendo el 62% varones y el 11% niños menores de 15 años. El índice de detección total fue de 3.1/100,000 habitantes y disminuyó desde 3.4/100,000 en 2004 hasta 2.8/100,000 en 2008. El 93% fueron clasificados como multibacilares y el 20.4% presentaron discapacidades Grado 2 en el momento del diagnóstico. Conclusiones: La lepra sigue siendo un problema de salud pública en la gobernación de Sohag. Es posible que se estén detectando tardíamente los nuevos casos por falta de percepción de la comunidad. Hay que implementar actividades de control de la lepra en las unidades de salud primaria para detectar recidivas y asegurar la adherencia del paciente al tratamiento (AU)

Introduction: Leprosy is a chronic and complex infectious illness; the new-case detection rate is better than prevalence as an indicator of disease trends. This study presents an analysis of pattern of new cases of leprosy detected annually from 2004 to 2008 in Sohag Governorate, Upper Egypt. Patients and methods: Data about patients with newly diagnosed leprosy were collected from Sohag leprosy hospital, the main referral centre in the governorate. Case detection rates (CDR) were calculated for each year by dividing the newly diagnosed cases by mid-year populations for the same year. Results: 587 patients were newly diagnosed between 2004 and 2008. The mean age of patients at diagnosis was 34 years, 62% were males, and 11% were children below 15 years of age. The overall leprosy case detection rate was 3·1/100,000 population and it decreased from 3·4/100,000 population in 2004 to 2·8/100,000 population in 2008. Ninety three percent were classified as multibacillary, and 20·4% had Grade 2 disability at diagnosis. Conclusions: Leprosy remains a health problem in Sohag Governorate. It is possible that new cases are being detected late owing to inadequate community awareness of the disease. Leprosy control activities should be provided in primary health care units in order to detect new cases, and continued surveillance is required to detect relapses and to ensure good patient compliance with treatment (AU)

Estrategia de la investigación para desarrollar nuevas herramientas para prevenir la lepra, mejorar los cuidados al paciente y reducir las consecuenicas de la lepra / No disponible

Una estrategia para la investigación para el desarrollo de nuevas herramientas para prevenir la lepra, mejorar el cuidado al paciente y reducir las consecuencias de la lepra (AU)

A Research Strategy to Develop New Tools to Prevent Leprosy, Improve Patient Care and Reduce the Consequences of Leprosy (AU)

Analysis of newly detected leprosy in Sohag Governorate, Upper Egypt, 2004-2008.

INTRODUCTION: Leprosy is a chronic and complex infectious illness; the new-case detection rate is better than prevalence as an indicator of disease trends. This study presents an analysis of pattern of new cases of leprosy detected annually from 2004 to 2008 in Sohag Governorate, Upper Egypt. PATIENTS AND METHODS: Data about patients with newly diagnosed leprosy were collected from Sohag leprosy hospital, the main referral centre in the governorate. Case detection rates (CDR) were calculated for each year by dividing the newly diagnosed cases by mid-year populations for the same year. RESULTS: 587 patients were newly diagnosed between 2004 and 2008. The mean age of patients at diagnosis was 34 years, 62% were males, and 11% were children below 15 years of age. The overall leprosy case detection rate was 3-1/100,000 population and it decreased from 3.4/100,000 population in 2004 to 2.8/100,000 population in 2008. Ninety three percent were classified as multibacillary, and 20.4% had Grade 2 disability at diagnosis. CONCLUSIONS: Leprosy remains a health problem in Sohag Governorate. It is possible that new cases are being detected late owing to inadequate community awareness of the disease. Leprosy control activities should be provided in primary health care units in order to detect new cases, and continued surveillance is required to detect relapses and to ensure good patient compliance with treatment.

[Survey of newly diagnosed Japanese leprosy patients].

We aimed to elucidate the patterns and trends of autochthonous leprosy in Japan from 1964 to 2009, to compare them with the findings from other studies of leprosy in decline. Data on registered leprosy cases in Japan in the period 1964-2009 were analysed with reference to trends in case detection, geographical distribution, age at diagnosis, sex, classification and family history. A consistent decline in leprosy case detection was observed in all areas of the country over the period 1964-2009. Highest incidence was consistently in Okinawa. Autochthonous leprosy has not been reported in anyone born in Japan since 1980. Increasing average age and a shift towards lower latitudes were demonstrated throughout the period. Analyses of data on autochthonous cases revealed patterns similar to those reported in other countries with declining leprosy. Okinawa has had the highest incidence of leprosy in all of Japan since the first national survey in 1900. Several possible explanations include the difference of leprosy control history between Okinawa and the rest of Japan, Okinawa's unique geographical condition, large-scale problem of stigma and discrimination against leprosy patients and delayed improvement of socio-economic conditions.

Epidemiological trends of leprosy in an urban leprosy centre of Delhi: a retrospective study of 16 years.

This study was done by collecting the retrospective data from 1994 to 2009 of patients attending the urban leprosy centre attached to the department of dermatology, STD & leprosy of PGIMER & Dr. R M L Hospital, New Delhi. The data was analysed according to age, sex, type of leprosy, leprosy reactions, deformities and relapse and compared with the national figures by comparison of proportions after taking the national data per 10,000 population. A total of 3659 patients attended our ULC (Urban Leprosy Centre) among which 2741 were male and 945 females (M:F-3:1). 669 patients (18.2%) were children. The data analysed show a gradual decline in new case detection rate with a marginal rise in 2005 and 2008. Percentage of MB cases was falling consistently till 2005 after which it showed an abrupt rise. The incidence of type 1 reaction varied from 21% in 1994 to 10% in 2009 in PB patients and from 6% in 1994 to 8% in 2009 in MB patients. The trend of type 2 reactions in MB patients showed a slow declining trend. MDT completion rate showed an impressive improvement from 56% in 1994 to 90% in 2009. The number of patients revisiting the ULC with features of relapse also showed a decrease in number. The pattern of visible deformities showed an almost constant trend similar to national figures. Improved MDT completion rate helps in reducing the disease transmission, severity, reactions and disabilities.

Caracterización epidemiológica de casos nuevos de lepra en el servicio de dermatología del hospital de clínicas de asunción, Paraguay. 3 años de estudio / No disponible

La lepra, enfermedad milenaria y estigmatizante, sigue estando vigente en nuestros días. Objetivo: Describir las características clínicas y epidemiológicas de los casos nuevos de lepra diagnosticados en la Cátedra de Dermatología del Hospital de Clínicas de Asunción desde diciembre de 2005 hasta noviembre de 2008. Material y método: Estudio retrospectivo de casos nuevos de lepra. Se analizaron los siguientes datos: género, edad, procedencia y formas clínicas. Resultados: Un total de 83 pacientes fueron diagnosticados en 3 años de revisión. El promedio de casos nuevos por año fue de 27.5, el 71% de los pacientes fue de sexo masculino. El promedio de edad de los pacientes fue de 44 años, con 2 pacientes menores de 18 años (2.5%) y 18 pacientes mayores de 60 años (21,5%). El mayor número de casos provenía del Departamento Central y Asunción (62,5%). El 64% de los pacientes presentó la forma clínica HL (JHansen Lepromatosa), siendo multibacilares el 93% de los pacientes. Conclusiones: A pesar de los esfuerzos de los programas de vigilancia y la instauración de la poliquimioterapia gratuita, la lepra sigue siendo una enfermedad de difícil control (AU)

Leprosy, ancient and stigmatizing disease still continues relevant today. Objective: To describe the clinical and epidemiological profile of new leprosy cases diagnosed at the Department of Dermatology at Clínicas Hospital, Asunción from December 2005 until November 2008. Material and Methods: Retrospective study of new cases of leprosy. We analyzed the following data: gender, age origin of the patient, and clinical forms. Results: A total of 83 patients were diagnosed at 3 years of review. The average of new cases per year was 27.5 71% of patients were male. The average age of the patients was 44 years, with 2 patients under 18 years (2.5%) and 18 patients over 60 years (21,5%). Most cases came form Central and Asunción (62,5%). 64% of patients had the LL clinical form (Lepromatous Hansen), and 93% of the patients were multibacillary. Conclusions: Despite the efforts of programs of surveillance and the introduction of free multidrug therapy, leprosy remains a difficult disease to control (AU)

Impacto del control de la lepra sobre la transmisión del M. Leprae: ¿Se está alcanzando la eliminación? / No disponible

En 1991 la Asamblea Mundial sobre la Salud decidió “eliminar la lepra como problema de salud pública” para el año 2000. La eliminación se definió como la reducción de la prevalencia global de la enfermedad a menos de 1 caso por 10.000. En el año 2000, la Organización Mundial de la Salud (OMS) anunció que la eliminación ya se había alcanzado globalmente. De manera convencional, el control de una enfermedad se define como la reducción de su carga hasta un nivel localmente aceptable. La eliminación de la enfermedad se define como la reducción a cero de la incidencia en un área geográfica definida y erradicación se define como la reducción permanente a cero de la incidencia mundial de la infección causada por un agente específico. Sin embargo en la lepra, la OMS limitó la eliminación o el control en vez de la transmisión, al emplear prevalencia en vez de incidencia de la enfermedad. Las estadísticas de la lepra normalmente informan sobre la prevalencia y detección de nuevos casos. Las tendencias en la incidencia cuando no hay cambios en la detección de casos en la lepra están muy influenciadas por factores operativos. Para la estrategia de la eliminación de la lepra se supuso que la MDT podría reducir la transmisión de M. Leprae, pero no se dispone de evidencias convincentes que lo confirmen. No se dispone de la información sobre el impacto de la MDT sobre la transmisión, debido a su largo período de incubación. También hay que considerar que la disminución en la detección de casos puede ser por otros motivos, como la vacunación BCG. Modelos matemáticos para la transmisión y control de la lepra revelaron que la estrategia de eliminación reduce lentamente la transmisión, con un declive anual predictivo en incidencias que va desde el 2% al 12%. La detección precoz era el factor clave para conseguir este declive. Pronósticos futuros sobre la carga mundial de la lepra revelan que se detectarán 5 millones de nuevos casos entre 2000 y 2020 y que en el año 2020 habrá 1 millón de personas con discapacidades de tipo grado 2 de la OMS. Se concluye en que ha habido un progreso sustancial en el control de la lepra, pero cuando se define la eliminación como la reducción a cero de la incidencia, resulta obvio que la lepra no esta eliminada. Para conseguir la eliminación de la lepra hay que llevar a cabo intervenciones efectivas para interrumpir la transmisión del M. Leprae y además disponer de técnicas prácticas de diagnóstico para detectar niveles de infección que pueden conllevar a la transmisión. Esto requiere una investigación exhaustiva en las especialidades de la epidemiología y microbiología (AU)

In 1991 the World Health Assembly decided to “eliminate leprosy as a public health problema” by the year 2000. Elimination was defined as reducing the global prevalence of the disease to less than 1 case per 10,000. En 2000 the World. Health Organization (WHO) announced that elimination was reached globally Conventionally control of disease is defined as the reduction of disease burden to a locally acceptable level. Elimination of disease is defined as the reduction to zero of the incidence in a defined geographical area, and eradication is defined as the permanent reduction to zero of the worldwide incidence of infection caused by a specific agent. In leprosy however, WHO limited elimination to control instead to transmission, by using prevalence and new case detection. Prevalence is linked to length of treatment, which has changed over time. Trends in new case detection rates only reflect trends in incidence rates when no changes occur in case detection, but in the past 25 years case detection in leprosy has been determined strongly by operations factors. For the leprosy elimination strategy it was assumed that MDT would reduce transmission are not readily available because leprosy has a long incubation period. Also declines in case detection may have other causes, such as BCG vaccination. Mathematical modeling of the transmission and control of leprosy showed that the elimination strategy reduces transmission slowly, with a predicted annual decline in incidence ranging from 2% to 12%. Early case finding was the key factor to attain this decline. Future projections of the global leprosy burden indicated that 5 million new cases would arise between 2000 and 2020, and that in2020 there would be 1 million people with WHO grade 2 disability. It is con concluded that substantial progress has been made to control leprosy, but when elimination of disease is defined as the reduction to zero of the incidence, leprosy is definitely not eliminated. To attain elimination of leprosy it is necessary to find effective interventions to interrupt transmission of M. leprae and practical diagnostic tools to detect levels of infection that can lead to transmission. This requires extensive research in the areas of epidemiology and microbiology (AU)

Community dermatology inclusive of leprosy: its past present and future.

The archives of leprosy and its global history are currently evolving in Oxford. A collection of documents and books are housed in the historical library of Sir William Osler under the heading of 'Public Health before and after Osler' and the history of leprosy can be found on http://www.leprosyhistory.org. A striking feature of the old books is their attention to the designation 'Lepra' and the evolution of not just leprosy but of the other differential diagnoses of the eighteenth and nineteenth century such as psoriasis.. Even in the twentieth century, the development of a major interest in Oxford led by Weddell was the innervation of the skin first in psoriasis and then in leprosy, joint meetings with Weddell, Cochrane, Browne, Rees and others over patients with leprosy, to the building of the Cochrane Annex and the work of Colin MacDougal in the Department of Dermatology.

Role of dermatologists in leprosy elimination and post-elimination era: the Brazilian contribution.

Dermatologists in Brazil have always been involved in care of leprosy patients, and have been alternating with public health physicians in the management of control policies. It is worth mentioning that Fernando Terra, founder of the Brazilian Society of Dermatology (BSD) in 1912, established the position of intern dermatologist at the Hospital dos Lizaros, in Rio de Janeiro, in 1913 (Souza-Araújo, 1952; Oliveira, 1991). In 1920, the dermatologist Eduardo Rabello formulated the first national public policy on the control of leprosy in the country, which was called 'Inspection of Prophylaxis of Leprosy and Venereal Diseases'. His son was an enthusiast of dermatological research and his main legacy was the polarity concept of leprosy (Rabelo, 1937). However, from 1930 to 1985, the public health physicians were in charge of the political guidelines that represented the period of establishing the vertical programmatic structure, with compulsory isolation of patients (1933-1962). Moreover, the federal states coordinated the control actions, based on the leprosy prophylaxis campaign. The dermatologists resumed the conduction of the control process in 1986, when multi-drug therapy (MDT) was implemented in the country, and in 1991, when decentralization of public healthcare services to the municipal level took place. In 2003 again, the dermatologists were no longer in control of the national policy. However, active dermatologists have acted in Brazilian references on diagnosis and treatment of Hansen's disease, at municipal, state and national levels. It is true that dermatologists have been getting away from leprosy control actions. And one could ask: who will replace this specialist? In the 'post-elimination' era, when the public primary healthcare technicians no longer consider leprosy of much significance, the knowledge of the expert in this disease and its differential diagnoses will be crucial.

Potential role of dermatologists and dermatological services in developing and sustaining the leprosy control referral system in resource constrained settings.

General Health Services that pay due attention to the management of skin conditions are opportune for suspecting and diagnosing early leprosy. In many developing countries, patients with dermatological conditions can only access specialist services in the larger cities and university hospitals; unaffordable costs make the services even less accessible if they can only be provided in the private sector. The high profile of dermatologists in the health services, gives them the opportunity to facilitate the development and implementation of a referral system that includes leprosy. This potential benefit for leprosy control must be initiated by current National Leprosy Programme Managers through establishing formal relationships with the dermatologists and involving them and other partners in the re-designing of leprosy control strategies to keep them in tandem with changing epidemiological patterns, national policies and on -going health sector reforms. The same health service managers should avail of the opportunities from the dermatologists (both in public and private sectors) about the current knowledge on the management and control of leprosy.

Role of dermatologists in leprosy elimination and post-elimination era.

Would it not have been better to have left out the word 'elimination' altogether in the question and do what WHO has done in its new strategic plan for 2006-2010, 'Global Strategy for further reducing the Leprosy Burden and Sustaining Leprosy Control Activities'? Why not use a title such as 'The Role of Dermatologists in reducing the Leprosy Burden and Sustainig Leprosy Control Activities'? Some elements of the 'foundation' of the elimination policy have been (and are still) very controversial, its definition and the unsubstantiated (up till now) claim that when reaching a prevalence rate of less than 1 per 10,000, the transmission of the infection would be interrupted and the incidence would therefore decline.