A field visit to Nimba County has revealed that much is to be done to support people affected by leprosy in this country and DAHW, the ILEP Co-ordinator for anti-leprosy activities in Liberia, is appealing to ILEP Members and other organisations to assist. 

Recently, Dr Diefenhardt, Deputy Chief Executive Officer, and I had the opportunity to visit Liberia on a fact-finding mission for the Deutsche Lepra- und Tuberkulosehilfe (DAHW). We travelled north towards the Guinean border to visit Ganta Leprosy & Tuberculosis (TB) Rehabilitation Centre. This is situated in Nimba County, which reportedly has a population of approximately 450,000. Liberia itself has 15 counties with a total population of about 3,000,000.

 
Examining a child for signs of leprosy
© Photo, Dr P de Koning, DAHW

“Ganta Rehab” as the centre is called is the only leprosy and TB referral hospital for the whole country. What struck us immediately was the relatively large number of freshly diagnosed leprosy cases, among them many children. When scrutinizing the statistics for the centre for 2008 we were able to ascertain that 133 new cases had been found, among them 27 children and three with grade 2 disabilities. For Nimba County this corresponds to an incidence of almost three per 10,000 population, with 20.3% children and a 2.25% grade 2 disability proportion. The very high incidence and child proportion with a very low grade 2 disability proportion seemed paradoxical to us, especially in a country torn by civil war for 15 years. 

A plausible explanation was offered to us by a very experienced leprosy worker in the centre. Practically very few cases of leprosy are self-reporting due to unawareness of the early signs of leprosy and due to the very high stigma placed on those patients where the disease has become too obvious to ignore. Once disabilities set in, the patient is branded and often banned from his or her village and sent to fend for him/herself in the bush. The patients put on treatment registers in the centre are almost all found during so-called “outreach village surveys”. These are organised once a month, when possible, and target villages suspected to be pockets of leprosy. These surveys do not detect the disabled cases banned to the bush, but relatively early cases, with many children among them.

 
Leprosy patient, who was found hiding in the bush,
with severe disabilities and multiple tropical ulcers
probably caused by malnutrition
© Photo, Dr P de Koning, DAHW

This explanation made the low grade 2 disability proportion plausible, but also made the incidence all the more alarming. If large numbers of (severely) disabled new patients are still hiding in the bush and were to be found and put on treatment registers, this would increase the incidence in Nimba dramatically, along with the grade 2 disability rate. But what about all the other counties in the country where no such outreach activities are being conducted at all? If those were to be entered into the equation and the figures being found in actual fact in Nimba county extrapolated to the whole country, the incidence (and, therefore, prevalence, assuming the majority of the cases are multibacillary (MB)!) would be shockingly high, much higher than the 276 new patients found and reported on in Liberia in 2008 by the National Leprosy and Tuberculosis Control Programme (NLTCP) (133 of these 276 are from Ganta alone). One might argue that Ganta is a border town and attracts patients from Guinea. We did establish that several of the patients put on treatment were from Guinea, but even if 50% of all patients were foreigners (which is highly unlikely) the incidence for Nimba County would still be 1.5 per 10,000 population.

In summary, the leprosy situation in Liberia is serious. Liberia has lost precious time due to its long civil war. Liberia most likely needs to be included in the World Health Organization’s list of last remaining countries with a prevalence of more than 1 per 10,000 population. To us as visitors it seemed like being thrown back 30 years in time to the pre-multi-drug therapy (MDT) era. DAHW, as the ILEP Member responsible for co-ordinating ILEP’s anti-leprosy activities in Liberia, is sounding the alarm bell for a serious problem that needs to be addressed at many levels: from capacity-building to efforts to reduce stigma through mass campaigns and health education. DAHW, as a funding agency, can not address these problems on its own. It is appealing to other ILEP Members and other organisations to assist.

Author and contact:
Dr Pieter de Koning, DAHW Medical Advisor, Würzburg, Germany
E-mail: pieter.de-koning@dahw.de  

 

 

Categories: Africa, Field Activities, International Collaboration, Liberia