Volume 67, Numher 2P,,,ite l in the U.S.A.

(ISSN 01-18-916X)

INTERNAI USAI, JOURNAI. Ur LJ.l'ROSY

Review of Leprosy Control Activities in Yemen'

Yasin AI-Qubati and Abdul Baset Mahuob AI-Dobai 2

Before 1923, Dr. J. C. Young, head of theKeith Falconer (Scotland) Mission, estab-lished a Leprosy ward as a branch of theMission hospital at Sheikh Othman, Aden.This ward was reorganized in 1923, and in1926 leprosy work was established as abranch of the Aden settlement of infectiousdiseases hospital (' )). In 1932 the Missionundertook the Leprosy work and a new lep-rosy hospital was opened accommodating25 patients (`)) in which leprosy patientswere treated with sodium hydnocarpate(Alepol) and chaulmoogra oil. This hospitalcontinued working until the early 1940s (5).In 1956 an organized outpatient leprosycontrol activity started in Aden, duringwhich time the patients were treated withdapsone/DDS (Avlosulfone) twice a weekfor 2 years. At this time, clinics in Aden,Sana'a, Taiz and Mukalla were the onlyplaces which provided basic medicai carefor leprosy patients ( 5 ).

Before 1964, leprosy patients were iso-Iated and kept in unsanitary houses ('). Be-tween 1964 and 1973, Taiz and Mukallawere the only places known for giving or-ganized medical care to leprosy patients,treating them with dapsone monotherapy.From 1973, leprosy work was carried outby the Missionaries of Charity in Taiz,Hodeidah and Al-Suknah. These activitieswere later taken over by the government.Until 1974, ali patients were given dapsonemonotherapy treatment ( 2). Later on ri-fampin was added daily for the first 3 to 6months. From 1983 multidrug therapy(MDT) as recommended by the WorldHealth Organization (WHO) was officiallyadopted by the National Leprosy ControlProgramme (NLCP) (" and Al-Qubati, Y.Together for elimination of leprosy. 1993Arabic manual).

' Received for publication on 8 July 1998.Acccpted for publication in revised forro 00 23 March1999.

Y. Al-Qubati, M.Sc., Director; A.13. M. AI-Dobai,National Leprosy Elimination Progranune, P. O. Box55722, Taiz, Republic of Yemmn. FAX 967-4-224019;e mail nlep@y.net.ye

150

In 1989 an agreement between theYemen Ministry of Public Health (MOPH)and the German Leprosy Relief Association(GLRA) was signed to strengthen the activ-ities of the NLCP. This led to greatly im-proved control efforts. A pilot program wasstarted in 1990 to serve the total populationof 5,119,960 in Dhamar, Taiz, Ibb andHodeidah ( 3). In the following years theNLCP activities were extended to the restof the country.

In 1992, a local nongovernment organi-zation called the Yemen Leprosy Elimina-tion Society (YELEP) was established tosupport and maintain the activities of theNLCP (Al-Qubati, Y. Together for elimina-tion of Leprosy. 1993 Arabic manual).

MATERIALS AND METHODSThe NLCP activities are now carried out

in 63 leprosy clinics distributed ali over thecountry. These clinics are run by primaryhealth care workers (PHCWs) and/or med-ical assistants (MAs) who were trained atthe NLCP headquarters. They suspect theleprosy cases, refer them to the supervisorswho visit the clinics on regular pre-sched-uled dates, hold the patient cards and givehealth education to the patients and theirfamilies. To keep them motivated, incen-tives are given to them by the NLCP foreach activity such as case finding, caseholding, release from treatment and de-faulter retrieval. Monthly supervision iscarried out by the dermatologista appointedat NLCP headquarters in Taiz. These der-matologists are especially trained in leprosyat the NLCP headquarters and at ALERT inEthiopia and the Schieffelin Leprosy Re-search and Training Center in Karigiri, In-dia. During their supervision, they confirmthe diagnosis of cases suspected by thePHCWs and MAs, check the regularity oftreatment, revise records, prescribe ortho-pedic shoes for deformed patients, trainPHCWs and MAs for MDT services, andgive health education to leprosy patients.

Mass community surveys to study theproblem of leprosy have been very difficult

—*— PREVALENCF RATE PER 10,000 POPULATION

—à— D1:1 LCCION RATE PER 10,000 POPULATION

r óE

xcn o

1-

67, 2

1.20

1.00

0.80

0.60

0.40

0.20

AI-Qubati and A1-Dobai: Leprosy Contrai in Yemen^151

1994^1995^1996^1997

FIG. 1^Prevalence and new case-detection rates in Yemen, 1990-1997.

0.001990^1991^1992^1993

to make dite to many reasons. The mostimportant factor is the high cost of suchsurveys competing with other prioritieswithin the Yemen MOPH. The secondmost important reason is the fact that lep-rosy patients are self-selected groups, notrepresenting the whole population ( 4). Pop-ulation-based studies to determine the epi-demiological indicators of leprosy have notyet been conducted in Yemen. Therefore,we were forced to rely on the informationcollected by the NLCP over the past 8years, and we also reviewed the NLCP su-pervision reports, cards and registers from1990 to 1997.

RESULTS AND DISCUSSIONIn Yemen leprosy declined from a peak

of 1400 cases with a prevalence rate of 1.1per 10,000 population in 1990 to 647 caseswith a prevalence rate of 0.37 at the end of1997 (The Table, Fig. 1). In most endemiccountries similar declines in prevalencewere observed with the number of countriesshowing prevalence rates above 1 case per10,000 population having been reducedfrom 122 in 1985 to only 55 at the begin-ning of 1997 (") The decline in the preva-lence trend was related to the increased ac-tivity of the control programs in Yemen aswell as in other countries. The period ofMDT is fixed for 2 years for MB cases and6 months for PB cases during the reviewperiod. However, the registered prevalence

rate had been found to be high in some gov-ernorates such as AI-Mahara, Hadramoutand Shebwa (Fig. 2), which have specialgeographic, economic and social situations,and in which MDT services were poor until1996 when it was initiated by a WHO Spe-cial Action Programme for the Eliminationof Leprosy (SAPEL).

A gradual increase in the annual newcase detection rate has been seen during thelast 8 years (The Table, Fig. 1) with a peakof new cases detected in 1993. This resultedfrom the extension of the NLCP to tive newgovernorates after the unification of Yemen.Other factors affecting the increase in theannual detection rate was the increased mo-tivation of field workers through special

2.5

1.5

0.5

Fia. 2. Leprosy prevalence rates in Yemen at lheend of 1997.

152^ International Journal o/'Leprosa'^ 1999

Tlllì TAHLI:. prevalence and new case-detection rates ür Yemen, 1990-1997.

^Prevalenee^Detectiunrate per^ rate per

^No. cases by^Grade

Year^ 10.0000

^10.000^Sex^ elassifieation'

^

1andII^population^population^M^I^MB^PB

^disabi li-lies

No. Rate No. Rate

1990 1400 1.10 185 0.15 68% 32% 93 92 46%1991 1095 0.90 376 0.30 69% 31% 265 111 23%1992 924 0.70 419 0.33 76% 24% 277 142 27%1993 1071 0.80 721 0.56 72% 28% 477 244 30%1994 877 0.60 309 0.20 79% 21% 255 84 20%1995 664 0.40 384 0.23 72% 28(7i 276 108 70%1996 765 0.45 456 0.27 67% 33% 304 152 16%1997 647 0.37 517 0.29 71% 29% 313 204 15%

MB = Mullibacillary leprosy; PB = paueibacillary leprosy.

programs jointly executed by GLRA,YELEP, and the WHO, which led to the in-crease of MDT coverage geographicallyuntil it reached uncovered or poorly cov-ered difficult remote areas in the desert ofthe empty quarter or in high mountains withmany deep wadies. Unfortunately, most ofthese new cases had Grade II deformitiesbecause they had acquired the disease sev-era) years before they were detected, due totheir living in difficult outreach arcas with alack of knowledge about the disease, socialstigma and the uneven distribution of.healthservices. It is now expected that the numberof new cases will probably remain at thesame levei for a few years to come until theeffect of MDT is expected to halt the trans-mission of the disease. This is also expectedin many endemic countries ( 12 ).

The gender distribution of leprosy pa-tients showed that 72% are males and 28%are females (The Table). This is a bit higherthan the sex distribution in most paris of theworld, where male preponderance is oftenobserved at the rate of 2:1 (`). Our figurescould be explained in two ways: a) the rela-tive lack of women may have resulted fromthe fact that medical examination of womenin Yemen is incomplete and less satisfac-tory due to social behavior and womenhave less chance for health services, and b)other factors with perhaps a true effect arereligious restriction of free mobility of fe-males and the wearing of a veil which couldresult in less exposure to the infection.Males, in general, are exposed to greaterrisks of infection as a result of their moreexposed life style (^).

To simplify the classification of leprosy,we adopted the WHO classification of MBand PB, according to the number of the le-sions and nerves involved, as ascertainedfrom the patients' individual records. Thesedata revealed that the proportion of MBcases was 66.3% and PB cases, 33.7%, i.e.,2:1 (The Table).

It was noted that the Grade I and II dis-abilities collectively equaled 46% in 1990and then decreased gradually to 14.9% in1997 (The Table). These percentagesclearly indicate the importance of field con-trol activities which include case finding,case holding and health education at thecommunity and individual leveis whichwere very effective in early case detectionand the prevention of any leprosy complica-tions.

The distribution of total cumulative newcases for each governorate between 1992and 1997 showed that the three major gover-norates, with a high case load were Taiz(31 %), Hadramout (24%) and Hodeidah(21%). The high case load in these gover-norates, and especially in Taiz (where theNLCP headquarters is located), is due to thefact that these governorates have a betterhealth infrastructure and that cases in thesurrounding governorates preferred to seekmedical cace in these governorates, some-times to escape the social stigma attached tothe disease in their communities.

CONCLUSIONA backlog of leprosy cases will continue

to supply the pool of leprosy with newcases and to reactivate the transmission of

67, 2^Al-Qubati and Al-Dobai: Leprosv Control in Yemen^153

the disease. Without field control activitiesand good health education programs theprevalence of leprosy will continue at a highlevei in Yemen.

SUMMARYLeprosy control activities in Yemen are

reviewed historically and up to the presenttime. Since 1983 the World Health Organi-zation's multidrug therapy has been used inthe National Leprosy Control Programme.Current activities are carried out in 63 lep-rosy clinics distributed alI over the countryand staffed by trained primary health careworkers and medicai assistants. In Yemenleprosy prevalence has declined from 1400per 10,000 population in 1990 to 647 in1997. Over the same period, new case de-tection rates per 10,000 population in-creased from 185 to 517. A backlog of lep-rosy cases continues to transmit the diseasein Yemen.

RESUMENSe hace una revisión histórica sobre las actividades

dei programa de control contra la lepra en Yemen.Desde 1983 se usa Ia poliquimioterapia sugerida por laOrganización Mundial de la Salud para el control de laenfermedad y las actividades dei programa se Ilevan acabo actualmente en 63 clínicas distribuidas en todo elPais y en cilas participar tanto el personal médico cal-ilicado como sus asistentes. En Yemen, la prevalenciade la lepra ha disminuido de 1400 por 10 000 habi-tantes en 1990, a 64 por 10 000 en 1997. En el mismoperiodo, la detección de casos nuevos aumentó de 185 a517. Seguramente algunos de los casos antiguos delepra continúan transmiticndo la enfermedad en Yemen.

RÉSUMÉNous avons revu les actions passées et présentes de

lutte contre la lèpre au Yémen. Depuis 1983, Ia poly-chimiothérapie reconunendée par 1'Organisation Mon-diale de la Santé est utilisée dans le cadre du Pro-

gramme national de lutte contre la lèpre. Actuellement,les actions de luttes sont effectuécs dans 63 cliniquesspécialisées réparties dans tous le pays, avec un per-sonnel médical entrainé et des assistants médicaux. AuYémen, la prévalence de la lèpre a décliné de 1400pour 10 000 habitants en 1990 à 647 en 1997. Pendantle même laps dc temps, le taux de détection de nou-veaux cas pour 10 000 habitants a augmcnté de 185 à517. Un groupe occulte de cas de lepre continue depropager Ia maladie au Yémen.

REFERENCESI. AI.-QuBATI, Y. Leprosy in Yemen. World Health

49 (1996) 18-19.AL-Qt'nxn, Y. and AL-Kun,crl, A. S. Dermatolo-gists combat leprosy in Yemen. Int. J. Dermatol.36 (1997) 920-922.

3. AL-QuBAn, Y. and At.-NABHANI, M. G. Formula-tion of a new leprosy control program in Republicof Yemen as a cooperation between GLRA andMOPH. (Abstract) Int. J. Lepr. 61 (1993) 45A.

4. BRYcEsoN, A. and PEAI:rzORAI-E, R. E. Leprosy.Edinburgh: Churchill Livingstone, 1990, p. 203.

5. Fxwniv. A. L. Notes on leprosy in Aden. Lepr.Rev. 39 (1959) 114-117.

6. Global evaluation of the introduction of multidrugtherapy (MDT). Lepr. Epidemiol. Bull. 4 (1990)1-57.

7. JAKEN1AN, P. and SMITH, W. C. S. Evaluation of amultidrug therapy programme of leprosy control.Lepr. Rev. 65 (1994) 289-296.

8. NooRUEE.N, S. K. The epidemiology of leprosy.In: Leproso. Hastings, R. C., ed. Edinburgh:Churchill Livingstone, 1985, pp. 15-28.

9. PI rRIE, P. W. R. Leprosy work in Aden settle-meut. Lepr. Rev. 5 (1934) 11-12.

10. PmisoN, E. S. Aden and its leprosy problem.Lepr. Rev. 5 (1934) 4-10.

11. WHO Ac'noN PROGRA\MME FOR THE EI.IMIN:1lloNot LI:PRosv. Status report updated. Geneva: WorldHealth Organization, 1997. WHO/LEP/97.4.

12. WHO STUD' GROUP. Epidemiology of leprosy inrelation to control. Geneva: World Health Organi-zation, 1985. Tech. Rep. Ser. 716.