Elimination of Leprosy as a public health problem by 2000 AD: an epidemiological perspective

Introduction: Leprosy is caused by Mycobacterium leprae and manifests as damage to the skin and peripheral nerves. The disease is dreaded because it causes deformities, blindness and disfigurement. Worldwide, 2 million people are estimated to be disabled by leprosy. Multidrug therapy is highly effective in curing leprosy, but treating the nerve damage is much more difficult. The World Health Assembly targeted to eliminate leprosy as a public health problem from the world by 2000. The objective of the review was to assess the successes of the leprosy elimination strategy, elimination hurdles and the way forward for leprosy eradication. Methods: A structured search was used to identify publications on the elimination strategy. The keywords used were leprosy, elimination and 2000. To identify potential publications, we included papers on leprosy elimination monitoring, special action projects for the elimination of leprosy, modified leprosy elimination campaigns, and the Global Alliance to eliminate leprosy from the following principal data bases: Cochrane data base of systematic reviews, PubMed, Medline, EMBASE, and the Leprosy data base. We also scanned reference lists for important citations. Key leprosy journals including WHO publications were also reviewed. Results: The search identified 63 journal publications on leprosy-related terms that included a form of elimination of which 19 comprehensively tackled the keywords including a book on leprosy elimination. In 1991, the 44th World Health Assembly called for the elimination of leprosy as a public health problem in the world by 2000. Elimination was defined as less than one case of leprosy per 10000-population. Elimination has been made possible by a confluence of several orders of opportunities: the scientific (the natural history of leprosy at the present state of knowledge), technological (multi-drug therapy and the blister pack); political (commitment of governments) and financial (support from NGOs for example the Nippon Foundation that supplies free multi-drug therapy) opportunities. Elimination created the unrealistic expectation that the leprosy problem could be solved by 2000. First, the elimination goal was not feasible in several areas which had high incidence of leprosy. Even if elimination was to be attained, significant numbers of new cases of leprosy would continue to occur and many people with physical imperfections, severe psychological, economic and social problems caused by leprosy would need continuous assistance. Extra-human reservoirs of Mycobacterium leprae, the relationship between leprosy and poverty, prevention of disabilities, lack of a reliable laboratory test to detect subclinical infection and a vaccine are also challenging issues. Conclusion: The evidence base available to inform on leprosy elimination is highly positive with the availability of multi-drug therapy blister packs. There are concerns that leprosy was not the right disease to be targeted for elimination as there are no reliable diagnostic tests to detect subclinical infection including the lack of a vaccine, extra-human reservoirs (monkeys and armadillos), increase in the burden of child cases, no good epidemiological indicator as prevalence instead of incidence is used to measure elimination. Multi-drug therapy treats leprosy very well but there is no proof that it concurrently interrupts transmission. The high social stigma, prevention of disabilities, and the relationship between leprosy and poverty are still major concerns.Key words: Leprosy, elimination, multi-drug therapy, public health, eradication, epidemiolog

Les Modalites Evolutives Du Zona Au Cours De L\'infection A Vih Au Cameroun

Introduction et But Peu d\'informations sont disponibles sur les complications du zona et la prise en charge globale de cette maladie chez les patients VIH-positifs dans les pays d\'Afrique sub Saharienne à l\'instar du Cameroun. Le taux de séroprévalence du VIH dans la population adulte générale au Cameroun à été rapporté à 5.5%. Notre étude visait à identifier les différentes modalités évolutives du zona au cours de l\'infection à VIH, en présence ou non d\'un traitement spécifique anti-herpétique et à explorer les pratiques thérapeutiques courantes. Matériel et Méthodes Il s\'agissait d\'une étude rétrospective et multicentrique sur 217 cas de zona, retenus parmi les 8000 consultations de dermatologie dans 4 hôpitaux universitaires de 1997 à 2002. La sérologie VIH était réalisée chez 90 patients. Résultats La séropositivité au VIH était de 85,55 % dans notre échantillon. La valeur prédictive positive du zona pour le VIH était de 79,22%. 42% des patients présentaient des modalités évolutives susceptibles de donner naissance à des complications à long terme de leur zona: névralgies post zostériennes 57,14% qui était plus fréquente chez les patients HIV positifs (p = 0,034); impétiginisation des lésions 17,58% ; cicatrices hypertrophiques 6,6% ; caractère multi métamérique 3,68 % et récidives 5,53%. 67,28 % des cas ont bénéficié d\'un traitement antiviral spécifique dont 106 patients traités à l\'Acyclovir et 40 à la valacyclovir. Parmi ces patients traités, 13,14% présentaient une névralgie post zostérienne contre 42,5 % parmi ceux n\'ayant pas reçu de traitement spécifique (p < 0,0001). Conclusion La névralgie post zostérienne est la complication la plus fréquente rencontrée au cours de l\'évolution du zona, et plus fréquente chez des patients VIH-positifs. A notre connaissance, cette étude est la première au Cameroun, faisant état d\'une réduction significative du risque de survenue de cette complication après prise d\'un traitement spécifique anti-herpétique. Cependant, il n\'en demeure pas moins que la disponibilité des ces molécules et leur accessibilité financière constituent un défi à relever en vue d\'un accès équitable aux soins pour les populations en Afrique sub saharienne. Introduction and Aim &#8232;Information on the management practices and outcome of Herpes zoster (shingles) during HIV infection is rather scarce in Sub Saharan African (SSA) countries like Cameroon. HIV seropositivity is reported to be 5.5% in the Cameroonian general adult population. We therefore decided to review the clinical course of Herpes zoster infection in the presence or absence of specific antiherpetic treatment, within the context of HIV infection in Cameroon. Materials and Methods This was a retrospective multi-centre study of 217 cases of shingles sampled from 8000 patients received in dermatology consultations in 4 University Teaching Hospitals in Yaounde and Douala between 1997 and 2002. HIV testing was done in 90 patients. Results HIV seropositivity was found in 85.55 % of cases. The positive predictive value of Herpes zoster for HIV infection was found to be 79.22%. Forty-two (42) % of the patients presented with a clinical course that led to long term complications: post-herpetic neuralgia in 57.14%, significantly more frequent in HIV positive patients (p = 0,034); impetiginisation of lesions in 17.58%; hypertrophic lesions in 6.6%; multi-dermatomal presentation in 3.68 % and recurrences in 5.53% of patients. Specific antiherpetic treatment was administered to 67.28 % of patients (106 patients treated with Acyclovir and 40 with Valacyclovir). This specific antiviral treatment significantly reduced the risk of developing post-herpetic neuralgia as only 13.14% of treated patients presented this complication compared to 42.5 % untreated patients (p < 0.0001). Conclusions Post-herpetic neuralgia is the most common complication of Herpes zoster and more common in HIV patients in our study population. To our knowledge, this is the first report in Cameroon of a significant reduction of the risk of post-herpetic neuralgia in HIV-positive patients with shingles who receive specific antiherpetic treatment. However, the availability and financial accessibility to these drugs are still major challenges which need to be addressed in order to contribute to the global access to health for the peoples of SSA. Keywords: HIV, Herpes zoster/shingles, treatment accessibility, evolution, Sub Saharan Africa.African Journal of Neurological Sciences Vol. 25 (2) 2006: pp. 21-2