In 1991 the World Health Assembly decided to eliminate leprosy as a public health problem by the year 2000. Elimination was defined as reducing the global prevalence of the disease to less than 1 case per 10,000 population. In 2000 the World Health Organization (WHO) announced that leprosy was eliminated globally
]. However, leprosy still remains a significant public health problem at national and sub-national levels in some endemic countries
]. The Malawi Leprosy Elimination Programme achieved the WHO defined leprosy elimination as a public health problem at the end of 1994. After this achievement, the country did not benefit from special support from WHO Leprosy Elimination Programme, which concentrated its support on the “final push strategy” to countries that had not achieved the leprosy elimination goal. This led to the reduction of support received from partners and to the progressive withdrawal of financial and technical support of LEPRA-UK from 1996 to 2009. Since then, the programme performed sub- optimally in essential components such as case finding, treatment with WHO-recommended MDT, prevention of disabilities and monitoring the programme performance through a sound recording, registration and reporting system.
Findings from this study confirmed the reduced performance of the programme and that high numbers of leprosy cases were occurring in some districts. Population-based prevalence estimates in all the four selected districts were off WHO elimination target. The estimated prevalence per 10,000 population in the study population ranged from 67 in Machinga to 194 in Mangochi. These estimates were higher than previously reported in Karonga (40–60) in 1980s
]. Among 37 new cases identified at community level, 9 were children aged less than 15
years old suggesting that the disease was being transmitted in the communities where the children came from
]. Prevalence/detection ratios were over 1 for all the years between 2006 and 2011, indicating poor case-holding of leprosy patients, poor recording and updating of leprosy registers at district level. Integration of leprosy activities in health centres was partial, contributing to long delay in diagnosis and longer periods of MDT treatments. Consequently, cure rates by cohort analysis of 2009
MB and 2010
PB cases were 33% and 63% respectively, far below the expected 80%. High leprosy MB ratio in the passive health facility-based data has been shown that it is not a sign of positive impact as previously thought but of severe under reporting to the extent of 73% when MB ratio reaches 47.5%
]. In Malawi, it could be even more since the proportion of MB cases in passive data was 88%, higher than in India which was at about 50%.
This study also demonstrated that active surveillance promotes early detection, treatment and gender balance in accessing leprosy services thereby reducing the risk of disability and stigma. This observation was consistent with other findings of modified leprosy elimination campaigns
]. Traditional house-to-house leprosy elimination campaign is expensive and unsustainable in resource- poor settings and is no longer encouraged by WHO
]. However, it could be modified to reduce the cost and maximise the health benefits
]. In this study people were mobilised to one place rather than health workers moving from house-to-house and were examined and treated for all skin diseases not just leprosy thereby maximizing the health benefits. Based on the facility-based data, there was no child case of leprosy from this population. The active community-based surveillance detected and put on treatment 9 children with leprosy. This suggested that child cases of leprosy were particularly missed by the facility-based self-reporting of cases. Information provided by this study on the distribution of leprosy lesions on the body is useful to health workers. Up to 62% of leprosy lesions were on the face, arms, legs where they could be easily seen in any person attending health facility irrespective of the reason for visiting the health facility. Enabling health workers to recognise leprosy lesions could make them to utilise the high attendance rate in public hospitals as an opportunity to detect leprosy cases that may have gone the health facility for a different reason.
Recent population-based prevalence estimates of skin conditions are not well documented in Malawi except 1980s data from Karonga
]. This study therefore provided an update that skin conditions were still a major public health problem affecting 18% of the population aged 5
years or more. Our findings that fungal infections, pityriasis versicolor in particular being the commonest skin infections were consistent with previous findings
]. Previous trials indicated that Whitfield's and clotrimazole creams were effective for the treatment of common fungal skin infections in Malawi with cure rates of 80%-90%. The lower cost made Whitfield's cream the treatment of choice for fungal infections of the skin in primary health care
]. Both Whitfield's and clotrimazole creams still seemed to be effective although the cure rates were currently unknown.
In summary, this study revealed the following challenges facing the Malawi Leprosy Elimination Programme: increasing and high prevalence which were over the leprosy elimination goal, high prevalence/detection ratios, lack of decentralisation to health centres for diagnosis and treatment, insufficient knowledge and skills of health centre staff and poor registration and recording system. There was therefore need for renewed political will and commitment by both government and partners for resources for the final push to eliminate leprosy at national and district level. The final push involves improving community awareness on signs and symptoms and dispelling the fear of leprosy, motivating people to seek treatment, enabling health workers to diagnose and treat patients early and ensuring that all patients are cured using multidrug therapy
Limitations of the study
The second step of the sampling process where people were mobilised at one place in the community could be the source of bias because it depended on the compliance. People who thought had leprosy might have selectively came forward thereby leading to over-estimation or might have stayed away for fear of being stigmatised thereby leading to under-estimation of leprosy prevalence. Chiefs and community health workers were involved in the mobilisation and promotion of community awareness for sustainability of leprosy elimination efforts. While recognizing the shortfall of mobilising people to one place rather than random selection of households and eligible participants, the method was more appropriate for promotion of community awareness, involvement and openness on leprosy. More people (more than twice the sample size) participated making it more representative of the study population. Over-representation of females (60% of participants were females) was another limitation of this study. Relatively fewer males participated in the study because there were away working in the fields as the study population was predominantly subsistence farmers. It was not known whether this group had different study characteristics.