Operational barriers to the implementation of multidrug therapy and leprosy elimination in Cameroon

Indian Journal of Dermatology, Venereology and Leprology, Sep/Oct 2009 by Nsagha, Dickson, Bamgboye, Elijah, Oyediran, Alain

Introduction

In 1980, the drug of choice for leprosy treatment was dapsone but because of widespread resistance, treatment became increasingly ineffective. Also, treatment was life-long, which discouraged the patients. [1]

Multidrug therapy (MDT) is a combination of three drugs for multibacillary leprosy and two drugs for paucibacillary cases. [1],[2] MDT enjoys a high degree of patient acceptability, with very low relapse rates following completion of treatment. Compliance is high because of the fixed and relatively short duration of treatment, low frequencies of side-effects, cost-effectiveness and definitive cure in the patient. [3],[4],[5],[6] Despite all these advantages, challenges such as improving MDT coverage in difficult-to-reach areas, completion rates and effective implementation strategies through general health services and primary health care settings exist. [7]

The World Health Organization (WHO) targeted to eliminate leprosy as a public health problem from endemic countries by the year 2000, i.e. reducing the prevalence to less than 1 per 10,000. In 2002, leprosy prevalence in Cameroon was 1.35/10,000 and paucibacillary and multibacillary defaulter rates were 22.2% and 37.5% respectively, and detection of new cases was decreasing. [8] But, 574 new cases were detected with 79 child cases giving a prevalence of 0.45/10,000 and a detection rate of 3.71% in 2004. [9] In the enclave Essimbiland, leprosy prevalence was 1.7/10,000 in 2008, [10] with high rate of case detection in children. [11]

Deficient knowledge about leprosy and its treatment [12] and ignorance [13],[14],[15] have affected leprosy treatment in Tanzania and other parts of the world. Community participation and behavioral studies can enhance practical understanding of local approaches toward MDT implementation and leprosy elimination. This study was carried out to identify factors that could hinder MDT implementation and leprosy elimination in an endemic region.

Methods

Study area

The study group was drawn from Boyo and Menchum divisions of northwestern Cameroon because they had the highest prevalence of leprosy (3.4/10,000 and 4.5/10,000 respectively). [11],[16],[17] These divisions still have the highest leprosy prevalence (Essimbiland= 1.7/10,000 and Boyo= 2/10,000) in the region. [10] In Boyo division, the study was concentrated in the Mbingo leprosarium and the surrounding villages of Mbingo II, Mejang, Baingo, Dr Jones' quarter and NewHope. In Menchum division, most leprosy patients were in Essimbiland. Because of the inaccessible nature of the terrain, this study was concentrated in Essimbi villages of Benakuma, Benahudu, Benage, Benabenge, Muteege, Atuoh and Vikuru, which had high leprosy prevalence. This study was conducted from June 1998 to October 2002.

Inclusion and exclusion criteria for leprosy patients, contacts and controls

The leprosy patients were those diagnosed clinically and bacteriologically in health facilities who were either on treatment or discharged cases living in neighbouring villages around the Mbingo leprosarium and in Essimbiland. All intra-familial contacts (wife, children and other relations) and extra-familial contacts (friends, peers, colleagues and villagers) were involved in the study. Controls were those who attended the Bamenda Hospital in Mezam division for reasons other than leprosy. They were selected based on a well-structured, guided questionnaire and those who said they either live or lived with a leper in the same household or quarter were eliminated from the study.

Design and setting

This was a descriptive observational case-control study that was community based in one low (Mezam division) and two high (Menchum and Boyo divisions) leprosy-prevalent areas. Leprosy patients constituted the cases and the contacts were a high-risk group for developing leprosy. Leprosy patients, their contacts and controls were matched for geographical location, age and sex.

Selection technique

The list of patients in the study area was established with assistance from health facilities. The patients in the different villages also assisted in the identification of other patients whose names were not in the registers. In the leprosarium, all the available leprosy patients on treatment, those discharged and living within the neighboring villages, including those rehabilitated, were involved. After identifying all the leprosy patients, all their contacts were recruited for the study.

A partly open and closed pre-tested structured questionnaire was administered to the respondents. Those who could read or write the English language filled the questionnaire and those who could not were communicated to through an interpreter in Bikom and Essimbi dialects. The questionnaire contained sociodemographic variables on age, sex, marital status, religion, geographical location and profession. Information on the cure of leprosy, duration of chemotherapy, MDT availability and problems patients faced in getting drugs constituted the dependent variables.