Leprosy resurging by the numbers

The numbers are the same, but the interpretation has caused great concern about the prevalence of leprosy in Nigeria. Is it spiking or dropping off? The World Health Organisation maintains a Global Health Observatory, which keeps health statistics across the world going back decades on record. In 2005, exactly 5,024 cases of leprosy were reported […]

The numbers are the same, but the interpretation has caused great concern about the prevalence of leprosy in Nigeria. Is it spiking or dropping off?

The World Health Organisation maintains a Global Health Observatory, which keeps health statistics across the world going back decades on record.

In 2005, exactly 5,024 cases of leprosy were reported in Nigeria. In 2015, the year for which latest records are available, only 2,892 cases reported.

The number for 2015 is a drop from 2,983 cases reported in 2014.

It also ranks Nigeria as having the third largest burden of leprosy in Africa-after the Democratic Republic of Congo and Ethiopia-and fourth in the world.

In the same year, DRC recorded 4,237 cases, compared with 3,970 in Ethiopia.

This year, global focus shifted to children affected by leprosy-and stopping them from becoming disabled.

On World Leprosy Day, health minister Isaac Adewole stirred concern with headlines that had him saying leprosy still posed a challenge due to pockets of high endemicity in some 15 states.

The list: Jigawa, Kano, Kaduna, Kebbi, Bauchi, Taraba, Niger, Kogi, Ebonyi, Abia, Cross River, Edo, Osun, Ogun and Lagos.

“Of utmost concern is the existence of new leprosy cases that are reported each year among the general population, including children and those with grade 2 disability,” he said.

Reduction or increase

Only 91 more cases of leprosy were reported in 2015, compared with 402 for 2014.

“We are still expecting the results from 2016, but there is a reduction, though very marginally,” says Dr Moses Onoh, coordinator of the Leprosy Mission Nigeria (TLMN).

“And even that is for those who report to the facility. A lot of them are hidden in the communities, without even coming out so we cannot beat our chest and say the problem has reduced.”

The reference to particular states is interpreted in terms of the “entire problem, not just new cases,” Onoh says.

“There are some particular states where the cases are increasing actually, but we are looking at national aggregates.”

Analysts are looking at peculiarities to the states in question-and one of them is a public attracted to big facilities. The presence of a dedicated facility in a state capital means more people running over there and pushing up the number of visits, cases or discoveries.

“It is also possible that some people did a very special intervention by going into the communities to search actively for them and found a lot hidden and not coming forward,” says Onoh.

“What he [Adewole] is telling us is that if we go and comb the nooks and crannies of the country, we will find them.”

Finding them

The stigma associated with leprosy keeps people away from disclosing and seeking early treatment-even in small primary health centres.

The result is dermatologist are finding-and have raised concern about-a rising number of leprosy cases that missed diagnosis in field work and showed up in tertiary hospitals.

“We have noticed we have resurgence,” Adebola Ogunbiyi, president of the National Association of Dermatologists, NAD, warned last year.

“We have a lot of atypical cases – they don’t look like leprosy to those who are trained in the field, and it is until they come to the hospital that we identify them.”

“It is not like we have a million cases. But if I see one case of lepromatous leprosy (that is infective, with coughing), then it is worrisome,” she explained.

“It is not in terms of huge numbers but the fact that we are still seeing that level of patients with the cases, that’s what’s worrisome.”

This particular resurgence was found more in adults than children, but that’s changing. Children are increasingly ending up with the condition.

Nearly one in 10 infections is among children, and disability results in up to 12% of them without prompt treatment, according to TLMN.

The germ that causes leprosy deadens nerve endings, removing feeling from body extremities. Feeling goes from the face, fingers and toes, and people living with leprosy (PALs) are unaware anything is wrong. They don’t feel pain in those parts, and continued work means more injuries. Infections follow injuries until fingers and toes get so damaged they require amputation to stem continuing infection.

That’s what experts called Grade 2 disability, and it is at point where it is irreversible, even when the leprosy is successfully treated. Human limbs, unlike reptiles, cannot regenerate.

The result: PALs with deformities end up begging alms or are confined to colonies where they are unable to help themselves, face stigma and unable to return to society.

Continued misconceptions about the condition fuels stigma against PALs, said Adewole.

“There were many mistaken beliefs about leprosy-that it was highly contagious, hereditary, heaven’s punishment-and these negatively affected persons with leprosy even after they have been cured.”

Isa Ali has lived with his condition for years and gotten successfully treated. But he still lives in Alheri Special Village, a colony designated for PALs in Yangoji, Kwali area council of the FCT, one of many where TLMN works in treatment, rehabilitation, education and empowerment.

In an impassioned speech, he talks about conditions in the village. relatives living with family members treated for leprosy have swelled the population of the village beyond its carrying capacity.

It started at a rate of one household per unit. Now a single room holds an entire household-man, wife or wives, children and grandchildren.

All use the five boreholes that serve the village-though one is not in use now.

Their children attend a school built on the grounds and their mothers take antenatal care at an onsite clinic which caters to residents’ TB and leprosy drugs.

The condition is curable, and the residents of Alheri are examples of successful treatment.

“The more people that show up, the more you see more problems like deformities,” says Onoh. “In the long run, it will be good we get them out, so they can stop transmitting it within the community.”

Nigeria has policy for leprosy but that is combined with tuberculosis, and experts worry there is not dedicated budget line for leprosy itself.

“You expect government to bring more money for us to go into the communities, but that is not coming,” says Onoh.

Campaigns, advocacy and lobbying have not seen “that part of the budget that is for leprosy,” he adds.

They also worry that concentration on improving primary health care which could find new cases of leprosy is not integrated enough to be effective-even though it is meant to help indirectly.

A conditional cash transfer set up for indigents in Niger benefited even PALs. PALs are Nigerians, and it follows that social support or a new health facility may benefit them also.

“But in practice, such facilities are not available to PALs. I am concerned. What I expect government to do is facilitate integration. A woman with leprosy can be pregnant, have a stroke, hypertension, any disease other people get. Let them also have access to those facilities,” says Onoh.

The national programme which combines tuberculosis and leprosy has mooted the idea of issuing certificates to treated PALs as testimony to their cure and aid to return to society. PALs still await that certification.