Epidemiological review of leprosy in the Western Pacific Region: 1983–2018 by Alexander Pascual

Epidemiological Review of Leprosy in the Western Pacific Region 1983–2018

World Health Organization Regional Office for the Western Pacific Manila, Philippines

Epidemiological review of leprosy in the Western Pacific Region: 1983-2018 © World Health Organization 2021 ISBN 978 92 9061 938 3 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. (http://www.wipo.int/amc/en/mediation/rules/) Suggested citation Epidemiological review of leprosy in the Western Pacific Region: 1983-2018. Manila: World Health Organization Regional Office for the Western Pacific; 2021. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. 1.Leprosy – epidemiology, prevention and control. 2. Research report. I. World Health Organization Regional Office for the Western Pacific.

(NLM Classification: WC335).

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Contents Acknowledgement ��  ix A note on the data ��  x Abbreviations ��  xi Executive summary �� xiii Part I. Epidemiological situation of leprosy in the Western Pacific Region �� 1 1.

Brief description of leprosy ��  1

2. Introduction ��  1 3.

Epidemiological situation ��  2 3.1 Global leprosy status ��  2 3.2 Summary data for the Western Pacific Region ��  3 3.3 Prevalence ��  6 3.4 New case detection ��  6 3.5 Other key monitoring indicators ��  12

Legislation related to discrimination ��  20 4.1 Background ��  20 4.2 Rationale ��  21 4.3 Segregation law and policy ��  22 4.4 Immigration laws and policies ��  22 4.5 Other laws ��  22 4.6 Limitations and way forward ��  23

Part II. Country profiles �� 25 American Samoa ��  25 Australia ��  28 Brunei Darussalam ��  31 Cambodia ��  34 China ��  37 China, Hong Kong SAR ��  40 China, Macao SAR ��  43 Cook Islands ��  46

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EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Fiji �� 49 French Polynesia �� 52 Guam �� 55 Japan �� 58 Kiribati �� 61 Lao People’s Democratic Republic �� 64 Malaysia �� 67 Marshall Islands �� 70 Micronesia (Federated States of ) �� 73 Mongolia �� 76 Nauru �� 79 New Caledonia �� 82 New Zealand �� 85 Niue �� 88 Northern Mariana Islands (Commonwealth of the) �� 91 Palau �� 94 Papua New Guinea �� 97 Philippines ��  100 Republic of Korea ��  103 Samoa ��  106 Singapore ��  109 Solomon Islands ��  112 Tokelau ��  115 Tonga ��  118 Tuvalu ��  121 Vanuatu ��  124 Viet Nam ��  127 Wallis and Futuna ��  130

Contents

Part III. Web-based Leprosy Dashboard ��  133 1. Overview ��  133 2.

Description of the Leprosy Dashboard ��  133

How to use the web-based Dashboard ��  134

Annexes ��  141 Annex 1. Definitions ��  141 Annex 2. Source of the data ��  143 Annex 3. List of countries/areas for which leprosy data were not available ��  144

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Figures and tables Fig. 1.

Distribution of new cases of leprosy by WHO Region, 2018 ��  3

Fig. 2.

Prevalence rate of leprosy in the Western Pacific Region, 1983–2018 ��  6

Fig. 3.

New case detection rate in the Western Pacific Region, 1983–2018 ��  7

Fig. 4.

Map showing new case detection rate in the Western Pacific Region, 2018 ��  7

Fig. 5.

New case detection rate for countries that reported at least one case in 2018 ��  8

Fig. 6.

New case detection rate and number for top 10 countries in the Western Pacific Region, 2018 ��  9

Fig. 7.

New case detection rate vs number, 2018 ��  9

Fig. 8.

Level of leprosy incidence and annual change ��  10

Fig. 9.

Trend in number of new cases in top 6 countries in numbers, 1983–2018 ��  11

Fig. 10. Trend in new case detection rate in top 6 countries in numbers, 1983–2018 ��  11 Fig. 11. New case detection rate by disease type in the Western Pacific Region, 1983–2018 ��  12 Fig. 12. Proportion of MB leprosy cases by country and area, 2014–2018 ��  13 Fig. 13. New case detection rate among children in the Western Pacific Region, 1983–2018 ��  14 Fig. 14. Proportion of child cases by country and area, 2014–2018 ��  14 Fig. 15. Number of new cases, child vs all cases (left) and new case detection rate among children (right), 2018 ��  15 Fig. 16. Proportion of female cases by country and area, 2014–2018 ��  16 Fig. 17. New case detection rate for cases with Grade 2 disability ��  16 Fig. 18. Proportion of cases with Grade 2 disability ��  17 Fig. 19. Change in Grade 2 disability rate from 2016 to 2018 ��  20 Fig. 20. Top page of the web-based Leprosy Dashboard �� 134 Fig. 21a. Customization of the Profile tab of the Leprosy Dashboard �� 135 Fig. 21b. Customization of the Profile tab of the Leprosy Dashboard �� 135 Fig. 21c. Customization of the Profile tab of the Leprosy Dashboard �� 136 Fig. 22. Snapshot of the Dashboard tab of the Leprosy Dashboard �� 137 Fig. 23. Snapshot of the Table tab of the Leprosy Dashboard �� 137 Fig. 24a. Customization of the Table tab of the Leprosy Dashboard �� 138 Fig. 24b. Customization of the Table tab of the Leprosy Dashboard �� 138 Fig. 24c. Customization of the Table tab of the Leprosy Dashboard �� 139 Fig. 25. Snapshot of the Comparison tab of the Leprosy Dashboard �� 139 Fig. 26a. Customization of the Comparison tab of the Leprosy Dashboard �� 140 Fig. 26b. Customization of the Comparison tab of the Leprosy Dashboard �� 140

Contents

Table 1. Number of new cases of leprosy by WHO Region, 2014–2018 �� 3 Table 2. Leprosy cases and monitoring indicators in the Western Pacific Region, 1983–2018 �� 4 Table 3. Leprosy cases and monitoring indicators in countries and areas in the Western Pacific Region, 2018 �� 5 Table 4. Progress against the global target of a zero Grade 2 disability among paediatric leprosy patients by 2020 compared to 2016 level (mid-term assessment) �� 18 Table 5. Progress against the global target of reduction in new cases with Grade 2 disability to less than one case per million population by 2020 compared to 2016 level (mid-term assessment) �� 19

vii

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Lead authors and contributors The lead authors of this report are Tauhid Islam, Kalpeshsinh Rahevar, Fukushi Morishita and Nobuyuki Nishikiori (former staff member) from the End TB and Leprosy Elimination unit at the World Health Organization (WHO) Regional Office for the Western Pacific, and Rie Yotsu, a WHO consultant. Masashi Teshima and Masato Yamauchi, WHO volunteers, supported the data management and analyses.

WHO staff members in regional and country offices Cornelia Hennig, Gemma Cabanos, Shalala Ahmadova, Tom Hiatt, Anuzaya Purevdagva, Padmasiri Eswara, Lepaitai Hansell, Narantuya Jadambaa, Ridha Jebeniani, Katsunori Osuga, Khanh Pham, Fabio Scano, Yanni Sun, Jacques Sebert, Mathida Thongseng, Subhash Yadav, Rajendra-Prasad Yadav, Dumawat Concepcion, Luciano Tuseo, Vilath Seevisay, Hieu Vu, Anupama Hazarika, Chen Zhongdan, Eunyoung Ko, Uhjin Kim and Chun Paul Soo.

National leprosy focal persons and national respondents who contributed to reporting and data verification Sharmaine Mageo, Saipale Fuimaono, Christina Barry, Cindy Toms, Noraskhin Hj Mohd Fadillah, Hajah Maslina bt Hj Mohsin, Kyaw Thu, Lai Ky, Du Xin, Chi Kuen Chan, Chou Kuok Hei, Edwina Tangaroa, Sambath Lay, Alumita, Mike Kama, Chima Mbakwem, Ken Jetton, Ludovic Floury, Waimanu Pulu, Marcelina Rabauliman, Yasunori Ichimura, Phonenaly Chittamany, Connie Bien Olikong, Margaret Kal, Yu Meiwen, Nukutau Pokura, Sakiusa Mainiwalala, Nguyen Ngoc Lam, Cecilia Arciaga, Darwin Mak, Norihisa Ishii, Erei Rimon, Kyung Eun, In Hyekyung, Nguyen Viet Nhung, Bounpheng Sodouangdenh, Danjaad Enkhmandakh, Lei Chin Ion, Muhamad Ismail, Chan Soi Fan, Hillia Langrine, Mayleen Jack Ekiek, J. Tsolmon, Jane Dowabobo, Julie Mart C. Rubite, Mme Oksana Segur, Alison Roberts, Andrea McNeill, Maina Pulu, Daniel C. Lamar, Helen Harding, Clarette Matlab, Miriam Pahun, Ernesto Villalon III, Robert Edward Thomsen, Lameka Sale, Christine Lefuka, Daniel Houillon, Connie Bien Olikong, Wang Yee Tang, Zhang Yiwen, Noel Itogo, Oliver Mapela, Tekie Iosefa, Malakai’ Ake, Louis Fonua, Nese Conway, Temilo Seono, Markleen Tagaro, Saen Fanai, Tran Hau Khang and Laurent Morisse.

viii

Acknowledgement We would like to thank all leprosy programme managers and statisticians from the countries and areas of the Western Pacific Region who provided valuable data and programmatic information for the compilation of this document.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

A note on the data This epidemiological report on leprosy was developed by compiling historical data for the WHO Western Pacific Region. Leprosy surveillance data are reported annually from countries and areas in the Region to the WHO Regional Office for the Western Pacific and forwarded to the WHO Global Leprosy Programme, where they are consolidated in a global leprosy report. In the process of developing this report, historical leprosy data were reviewed and validated by national leprosy elimination programmes to ensure consistency with the nationally available data. Therefore, the data presented in this report may contradict data presented in previous WHO reports. Further information about the sources of the data can be found in Annex 2.

Abbreviations BCG CSV IEC IQR LEC MB MDT NGO PB P/D PICs ROM SAPEL TB WHO

bacille Calmette-Guérin comma-separated values information, education and communication interquartile range leprosy elimination campaign multibacillary multidrug therapy nongovernmental organization paucibacillary prevalence/detection Pacific island countries and areas rifampicin-ofloxacin-minocycline special action project for elimination of leprosy tuberculosis World Health Organization

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

International Organization for Standardization codes for countries and areas of the Western Pacific Region Used in various figures in this report

ASM AUS BRN CHN COK FJI FSM GUM HKG JPN KHM KIR KOR LAO MAC MHL MNG MNP MYS NCL NIU NRU NZL PHL PLW PNG PYF SGP SLB TKL TON TUV VNM VUT WLF WPR WSM

xii

American Samoa Australia Brunei Darussalam China Cook Islands Fiji Micronesia (Federated States of ) Guam Hong Kong SAR (China) Japan Cambodia Kiribati Republic of Korea Lao People’s Democratic Republic Macao SAR (China) Marshall Islands Mongolia Northern Mariana Islands (Commonwealth of the) Malaysia New Caledonia Niue Nauru New Zealand Philippines Palau Papua New Guinea French Polynesia Singapore Solomon Islands Tokelau Tonga Tuvalu Viet Nam Vanuatu Wallis and Futuna Western Pacific Region (not an International Organization for Standardization code) Samoa

Executive summary Since the adoption of World Health Assembly resolution WHA44.9 in 1991, great progress has been made in the fight against leprosy. However, the historical trends and the current situation for leprosy epidemiology vary substantially across countries in the World Health Organization (WHO) Western Pacific Region. This report, Epidemiological Review of Leprosy in the Western Pacific Region 1983–2018, presents all available historical data for all countries and areas of the Region from1983 to 2018, together with programmatic and policy milestones. It was developed by compiling leprosy surveillance data reported annually from countries and areas in the Region to the WHO Regional Office for the Western Pacific during this time, which were further reviewed and validated by national leprosy elimination programmes to ensure consistency with the nationally available data. The Western Pacific Region accounted for 4% of new leprosy cases worldwide in 2018. The number of registered cases in the Region decreased by 89.5%, from 68 313 cases in 1991 to 7876 cases in 2018. In 2018, the prevalence rate in the Region was 0.04 per 10 000 population, which was six times lower than the global average. The highest prevalence rate was found in Kiribati with 18.6 per 10 000 population, followed by the Marshall Islands with 11.0 per 10 000 population and the Federated States of Micronesia with 10.7 per 10 000 population. The highest number of registered cases was reported in the Philippines with 4970 cases, followed by China with 970 cases and Papua New Guinea with 626 cases. In 2018, countries and areas for which the prevalence rate was above the elimination level included the following six: American Samoa, Kiribati, the Marshall Islands, the Federated States of Micronesia, Nauru and Tuvalu. The number of new cases detected in the Region decreased by 72.1%, from 15 002 cases in 1991 to 4193 cases in 2018. The countries with the three highest new case detection rates were Kiribati with 149 per 100 000 population, the Federated States of Micronesia with 113 per 100 000 population and the Marshall Islands with 101 per 100 000 population. Of 37 countries and areas in the Region, seven countries and areas (18.9%) did not report new leprosy cases in 2018. Across the Region, the proportion of multibacillary (MB) leprosy cases among total new cases increased from 69.0% in 1997 to 82.8% in 2018, with wide differences among countries. The number of child leprosy cases decreased by 62.8%, from 1240 cases in 1997 to 450 cases in 2018. Child cases represented 10.7% of total new cases in 2018. In 1998, the Region achieved the global target of reducing the occurrence of new cases with Grade 2 disabilities to less than one case per million population. In 2018, the number of new cases with Grade 2 disabilities was 258, yielding a rate of 0.13 per million in the Region. In the past, people affected by leprosy were forcibly quarantined by law in isolated hospitals, sanatoria or leprosy colonies. Even today, in some countries, people affected by leprosy and their family members may be directly or indirectly discriminated against in society. Notable areas include marriage, employment, and the use of public places including hotels, restaurants and transport. The United Nations General Assembly has adopted a resolution that calls for the elimination of discrimination against people affected by leprosy and their family members. There is growing international momentum to review the current situation as a first step toward addressing legal discrimination against people affected by leprosy and their family members. A regional review of legislation demonstrated that laws that directly or indirectly discriminate against people affected by leprosy and their family members were in force in the past in some countries and areas of the Western Pacific Region, and that some remain in effect today, regardless of whether they are enforced. The WHO Regional Office for the Western Pacific has developed a web-based Leprosy Dashboard that enables tabulation and visualization of all indicators and data presented in this epidemiological report. The dashboard is accessible to all and can be customized to suit a user’s preferences. Figures and data generated by the dashboard can be downloaded.

xiii

Part I. Epidemiological situation of leprosy in the Western Pacific Region 1. Brief description of leprosy Leprosy is a chronic infectious disease caused by Mycobacterium leprae. It usually affects the skin and peripheral nerves but has a wide range of clinical manifestations. The disease is classified as paucibacillary (PB) or multibacillary (MB), depending on the bacillary load. PB leprosy is a milder disease characterized by few (up to five) hypopigmented, anaesthetic skin lesions (pale or reddish). MB leprosy is associated with multiple (more than five) skin lesions, nodules, plaques, thickened dermis or skin infiltration and, in some instances, involvement of the nasal mucosa, resulting in nasal congestion and epistaxis. Involvement of certain peripheral nerves also may be noted, sometimes resulting in the characteristic patterns of disabilities. In most cases of both PB and MB disease, the diagnosis is straightforward. But in a small proportion of cases, those without anaesthetic patches require examination by a specialist to detect other cardinal signs of the disease, including nerve involvement, along with a positive laboratory test (the slit skin smear). Among communicable diseases, leprosy is a leading cause of permanent physical disabilities. Timely diagnosis and treatment of cases, before nerve damage has occurred, is the most effective way of preventing disabilities due to leprosy. Effective management of leprosy complications, including reactions and neuritis, can prevent or minimize the onset of further disabilities. The disease and its associated deformities bring social stigma and discrimination against patients and their families in many societies. The mode of transmission of M. leprae remains uncertain, but most investigators believe that it is spread from person to person, primarily as a nasal droplet infection. The incubation period of five to seven years is unusually long for a bacterial disease. The peak age of onset is young adulthood, usually 20–30 years old; the disease is rarely seen in children aged under 5 years. While humans are considered to be the major host and reservoir of M. leprae, other animal sources, including the armadillo, have been incriminated as reservoirs of infection. The epidemiological significance of these findings is unknown but is likely to be very limited, except perhaps in North America. Unlike tuberculosis, there is no evidence to suggest an association between HIV infection and leprosy. Bacille Calmette-Guérin (BCG) vaccination is known to have some protective effect against the disease.

2. Introduction The World Health Organization (WHO) Western Pacific Region comprises 37 countries and areas with a total population of approximately 1.9 billion people,1 more than one quarter of the world’s population. The Region is one of the most diverse WHO regions geographically and economically. It stretches over a vast area, from China in the north and west, to New Zealand in the south and French Polynesia in the east. It includes developed countries such as Australia, Japan, New Zealand, the Republic of Korea and Singapore, as well as countries with the fastest growing economies such as China, Viet Nam, and more recently Mongolia, Papua New Guinea and the Lao People’s Democratic Republic.2 Of the 37 countries and areas in the Region, 21 are small Pacific island countries and areas (PICs) that account for 0.17% of the total population.1 Globally, the prevalence of leprosy decreased from more than 5 million cases in the mid-1980s to less than 200 000 cases by 2018.3 The development of multidrug therapy (MDT) to treat leprosy in the early 1980s 1 2

Population Division [website]. New York: United Nations; 2018 (https://www.un.org/development/desa/pd/, accessed on 10 September 2018). World Economic Outlook Databases [website]. Washington DC: International Monetary Fund; 2015 (https://www.imf.org/en/Publications/SPROLLs/world-economicoutlook-databases#sort=%40imfdate%20descending, accessed on 10 October 2015). Weekly epidemiological record. No. 35/36 Geneva: World Health Organization; 2019; 94: 389-412.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

represented an important step forward in the fight against the disease. MDT was first introduced in 1982 and was administered worldwide by 1990. A considerable reduction in prevalence was achieved during this phase. At the Forty-fourth World Health Assembly in 1991, a resolution was adopted that aimed for the global elimination of leprosy as a public health problem by the year 2000.4 Elimination as a public health problem was defined as reaching a prevalence of less than 1 per 10 000 population. The elimination campaign provided an opportunity to increase political commitment, mobilize resources and intensify activities. The elimination target was achieved at a global level by the end of 2000. With few exceptions, all countries reached the goal of elimination at national level by 2005.5 From 2000 to 2020, four five-year global leprosy strategies were implemented, aiming at improving availability and accessibility of leprosy services, ensuring programme sustainability and controlling morbidity.6 These implementation strategies, in combination with effective chemotherapy, made remarkable contributions to a continued decline in the global burden of leprosy after the millennium. Over the past 20 years, more than 14 million leprosy patients have been cured, about 4 million of them since 2000.7 In the Western Pacific Region, MDT implementation began in 1985. It reached 10% coverage in 1988 and almost 100% by 1994.8 Elimination of leprosy was achieved at the regional level and in 15 countries at the national level in 1991.8 Today, Kiribati, the Marshall Islands and the Federated States of Micronesia are regarded as countries yet to eliminate leprosy as a public health problem. From 2000 to 2018, several countries that had achieved the elimination level sporadically returned to a pre-elimination level, mainly due to relatively small population sizes and cases of foreign origin. They included American Samoa, Nauru, Palau and Tuvalu.

3. Epidemiological situation 3.1 Global leprosy status Across the world there has been an enormous reduction in the number of patients registered for treatment, but new leprosy cases continue to occur. In order to identify and keep track of the global leprosy status, leprosy surveillance data are reported annually from countries and areas in the Region to the WHO Regional Office and forwarded to the WHO Global Leprosy Programme, where they are consolidated in a global leprosy report. In 2018, there were 184 212 registered cases3 and 208 619 new cases9 of leprosy worldwide (Table 1). The prevalence rate was recorded at 0.24 per 10 000 population, and the new case detection rate was 2.74 per 100 000 population at global level.3 The WHO South-East Asia Region accounted for 71.2% of the global new caseload, followed by the Region of the Americas (14.8%) and the African Region (9.9%) (Fig. 1). The Western Pacific Region accounted for 2.0% of new leprosy cases. In 2018, the country reporting the highest number of new leprosy case was India with 120 334 cases, followed by Brazil with 28 660 cases and Indonesia with 17 017 cases. These three countries accounted for more than 80% of the global leprosy burden. Of 159 countries that submitted data in 2018, 15 reported more than 1000 new cases. In the Western Pacific Region, only the Philippines reported more than 1000 new cases. The following sections of this report provide analysis of leprosy surveillance data reported annually from countries and areas in the Western Pacific Region to the WHO Regional Office from 1983 to 2018, which were reviewed and validated by national leprosy elimination programmes to ensure consistency with the 4 5 6

7 8

WHA 44.9 Leprosy, HbK Res, Vol. III (2nd ed.), 1.16.8: Eleventh Plenary meeting, 13 May 1991. Weekly epidemiological record. No. 32. Geneva: World Health Organization; 2006: 309-316. Enhanced global strategy for further reducing the disease burden due to leprosy (2011-2015): plan period: 2011-2015). New Delhi: WHO Regional Office for SouthEast Asia; 2009 (https://apps.who.int/iris/handle/10665/205004). Leprosy [website]. Geneva: World Health Organization; 2019 (http://www.who.int/mediacentre/factsheets/fs101/en/, accessed on 10 September 2019). Overview and epidemiological review of leprosy in the WHO Western Pacific Region 1991 - 2001. Manila: WHO Regional Office for the Western Pacific; 2003 (https:// apps.who.int/iris/handle/10665/206979). Updated/validated data were used for the Western Pacific Region. Data for other regions (excluding WHO European Region) were taken from Weekly epidemiological record. No. 32. Geneva: World Health Organization; 2006: 309-316.

Part I. Epidemiological situation of leprosy in the Western Pacific Region

nationally available data. Therefore, the data presented in this report may contradict data presented in previous WHO reports. Further information about the sources of the data can be found in Annex 2.

Table 1.

Number of new cases of leprosy by WHO Region, 2014–2018 2014

WHO Region

No.

2015 %

No.

2016 %

No.

2017 %

No.

2018 %

No.

Africa

18 280

8.6

21 219

10.0

20 705

9.5

20 828

9.9

20 586

9.9

Americas

33 276

15.6

28 806

13.6

27 368

12.6

29 127

13.8

30 957

14.8

2 342

1.1

2 167

1.0

2 858

1.3

3 563

1.7

4 338

2.1

0.0

Eastern Mediterranean Europe South-East Asia

154 834

72.7

156 118

73.6

163 094

74.8

153 487

72.7

148 495

71.2

Western Pacific

4 335

2.0

3 645

1.7

3 914

1.8

4 140

2.0

4 193

2.0

Total

213 067

211 973

217 971

211 182

208 619

Source: WHO, Weekly epidemiological record. No. 35/36 2019, 94, 389-412. Data for the Western Pacific Region were updated using new data updated/validated by countries.

Fig. 1.

Distribution of new cases of leprosy by WHO Region, 2018

2.0%

9.9%

14.8%

2.1%

71.2%

Africa Americas Eastern Mediterranean Europe South East-Asia Western Pacific

3.2 Summary data for the Western Pacific Region Table 2 shows key leprosy monitoring indicators for the Western Pacific Region from 1983 to 2018. Table 3 shows key leprosy monitoring indicators for countries and areas in the Region in 2018. In the Region, leprosy surveillance data have been available since 1983. However, the number of reporting countries and areas varies across different years. In particular, the data were not available in many countries and areas in the early years. Missing data for a few countries with large populations and/or a large number of registered and new cases between 1983 and 1986 considerably affected and distorted the regional trend, especially for prevalence and new case detection rates. Other data disaggregated by demography (cases among children and women), disease type (MB and PB cases) and disability status (cases with Grade 2 disability) were also influenced by the gradual increase in the reporting coverage, as well as the availability of data within individual countries and areas. These points should be noted as limitations to the regional analysis. Figures presented in the later sections of this report omit some data from the early years that were most probably distorted by the reporting coverage.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Table 2. Leprosy cases and monitoring indicators in the Western Pacific Region, 1983– 2018 Year 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Population Registered Prevalence New Detection per (000) cases per 10 000 cases 100 000 159 509 297 833 1 366 618 1 391 015 1 433 140 1 459 926 1 426 553 1 506 375 1 467 438 1 526 864 1 545 616 1 460 290 1 477 929 1 618 583 1 506 621 1 522 207 1 666 566 1 680 646 1 693 748 1 582 255 1 720 239 1 728 766 1 742 574 1 747 097 1 757 936 1 772 064 1 787 621 1 798 335 1 808 508 1 818 996 1 828 251 1 837 692 1 828 563 1 900 819 1 911 643 1 921 989

84 509 81 110 182 250 79 103 150 816 134 875 109 050 86 534 68 313 44 785 40 737 38 767 30 722 25 453 23 309 19 132 14 187 12 371 11 757 11 036 10 456 9 947 9 463 9 808 8 124 9 762 13 403 8 237 7 380 7 357 7 070 7 322 5 773 5 820 7 104 7 876

5.30 2.72 1.33 0.57 1.05 0.92 0.76 0.57 0.47 0.29 0.26 0.27 0.21 0.16 0.15 0.13 0.09 0.07 0.07 0.07 0.06 0.06 0.05 0.06 0.05 0.06 0.07 0.05 0.04 0.04 0.04 0.04 0.03 0.03 0.04 0.04

5 229 5 018 5 443 11 357 11 670 10 442 11 814 13 302 15 002 13 768 11 392 12 771 11 943 13 114 13 608 10 616 9 529 8 406 7 417 7 210 6 208 6 220 7 196 6 042 5 863 5 876 5 333 5 058 4 790 5 419 4 613 4 439 3 645 3 914 4 140 4 193

3.28 1.68 0.40 0.82 0.81 0.72 0.83 0.88 1.02 0.90 0.74 0.87 0.81 0.81 0.90 0.70 0.57 0.50 0.44 0.46 0.36 0.36 0.41 0.35 0.33 0.33 0.30 0.28 0.26 0.30 0.25 0.24 0.20 0.21 0.22 0.22

MB % 18.1 18.1 13.7 37.9 39.8 44.1 42.2 19.3 16.3 34.8 36.0 41.4 67.4 65.9 69.0 68.3 70.6 75.2 77.3 77.0 78.1 77.8 81.3 80.1 68.3 82.4 80.8 82.3 79.4 76.3 78.8 78.9 82.2 79.1 80.3 82.8

Child Disability Disability % Female % % per million 7.8 7.1 6.0 4.6 6.0 3.0 1.6 2.6 1.2 3.4 2.7 3.8 4.9 8.6 9.1 8.4 9.4 7.8 6.7 7.0 7.1 8.2 7.4 7.6 5.6 7.0 8.8 7.8 9.6 9.4 9.9 11.1 10.8 9.5 12.0 10.7

0.2 0.3 0.2 0.1 0.1 0.1 0.2 0.2 0.1 0.3 0.2 0.2 8.0 8.0 7.8 8.0 7.5 7.3 9.7 9.1 8.1 20.5 16.4 17.6 26.8 24.5 32.3 26.3 34.2 33.2 32.3 32.1 32.5 34.6 34.4 35.1

15.9 12.7 12.2 6.1 6.1 5.9 5.7 5.4 4.8 11.5 12.6 13.0 15.4 12.5 15.2 14.3 12.4 12.4 11.6 11.3 11.3 12.2 9.4 10.9 10.2 10.1 12.2 10.4 11.5 10.5 8.5 7.5 8.6 9.2 7.2 6.2

5.22 2.13 0.49 0.50 0.49 0.42 0.47 0.48 0.49 1.04 0.93 1.13 1.24 1.01 1.37 1.00 0.71 0.62 0.51 0.52 0.41 0.44 0.39 0.38 0.34 0.34 0.36 0.29 0.31 0.31 0.21 0.18 0.17 0.19 0.16 0.13

Note: The number of reporting countries and areas varies across different years. In particular, the data were not available in many countries and areas in the early years. Population data presented here are the total population of countries and areas for which any data were available in the WHO regional leprosy database. The data for China were not available in 1983 and 1984, which largely affected the regional data and calculation of monitoring indicators. A list of countries and areas with non-available leprosy data is provided in Annex 3.

Part I. Epidemiological situation of leprosy in the Western Pacific Region

Disability %

Disability per million

3 6 1 151 521 5 0 0 9 0 8 2 173 71

5.41 0.02 0.23 0.93 0.04 0.07 0 0 1.02 0 4.83 0 149.33 1.01

100.0 100.0 100.0 56.3 89.4 80.0 NA NA 77.8 NA 100.0 100.0 41.0 88.7

33.3 0.0 0.0 9.3 1.3 0.0 NA NA 11.1 NA 12.5 0.0 27.8 12.7

33.3 50.0 0.0 39.7 36.9 100.0 NA NA 11.1 NA 12.5 50.0 51.5 21.1

0.0 0.0 0.0 14.6 19.0 0.0 NA NA 22.2 NA 0.0 0.0 2.9 25.4

0.00 0.00 0.00 1.35 0.07 0.00 0.00 0.00 2.26 0.00 0.00 0.00 43.16 2.55

31 528 58 113

288 0.09 64 10.96 121 10.74

182 59 127

0.58 101 112.75

72.0 54.2 54.3

5.5 30.5 30.7

23.6 44.1 35.4

5.5 0.0 2.4

0.32 0.00 26.63

0 8 8 3 0 3

0 74.98 2.86 0.06 0 5.77

NA 87.5 12.5 100.0 NA 100.0

NA 0.0 50.0 0.0 NA 0.0

NA 0.0 62.5 0.0 NA 33.3

NA 0.0 0.0 0.0 NA 0.0

0.00 0.00 0.00 0.00 0.00 0.00

18 1 0.56 1 8 606 626 0.73 502 106 651 4 970 0.47 2 176 NA NA NA NA 51 172 129 0.03 6 196 6 0.31 5 5 757 6 0.01 6 653 41 0.63 47 1 0 0 0 103 1 0.1 1 12 9 7.82 8 293 4 0.14 5 95 546 203 0.02 96 12 0 0 0 1 921 989 7 876 0.04 4 193

5.58 5.83 2.04 NA 0.01 2.55 0.1 7.2 0 0.97 69.52 1.71 0.1 0 0.22

100.0 0.0 82.1 27.3 89.9 6.8 NA NA 100.0 0.0 60.0 0.0 66.7 0.0 61.7 21.3 NA NA 100.0 0.0 50.0 50.0 80.0 0.0 92.7 0.0 NA NA 82.8 10.7

0.0 39.2 33.6 NA 16.7 0.0 33.3 42.6 NA 0.0 37.5 80.0 25.0 NA 35.1

0.0 5.2 2.3 NA 16.7 0.0 0.0 6.4 NA 0.0 0.0 0.0 18.8 NA 6.2

0.00 3.02 0.48 NA 0.02 0.00 0.00 4.60 0.00 0.00 0.00 0.00 0.19 0.00 0.13

3 170 11 280 4 743 17 57

0 8 14 3 0 3

0 7.5 0.5 0.01 0 0.58

New cases

Female %

Child %

8 1.44 11 0 1 0.02 70 0.04 970 0.01 9 0.01 1 0.02 0 0 9 0.1 0 0 6 0.36 2 0 215 18.56 77 0.11

Detection per 100 000

55 24 898 429 16 250 1 427 648 7 372 632 18 883 278 166 127 202 116 7 062

Registered cases

MB %

American Samoa Australia Brunei Darussalam Cambodia China China, Hong Kong SAR China, Macao SAR Cook Islands Fiji French Polynesia Guam Japan Kiribati Lao People’s Democratic Republic Malaysia Marshall Islands Micronesia (Federated States of) Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands (Commonwealth of the) Palau Papua New Guinea Philippines Pitcairn Island Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna Western Pacific Region

Population (‘000)

Country/area

Prevalence per 10 000

Table 3. Leprosy cases and monitoring indicators in countries and areas in the Western Pacific Region, 2018

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

3.3 Prevalence Fig. 2 shows the trend of the prevalence rate in the Western Pacific Region from 1983 to 2018. It declined sharply in the late 1980s and early 1990s. This remarkable reduction was mainly driven by increased MDT implementation during the period. After the late 1990s, the rate of the decline became slower. From 2000 to 2018, the decline continued but it was less pronounced than during the previous decade. After the adoption of the World Health Assembly resolution that aimed for global elimination of leprosy, the number of registered cases decreased by 89.3% – from 68 313 cases in 1991 to 7876 cases in 2018. In 2018, the prevalence rate in the Region was 0.04 per 10 000 population, six times lower than the global average of 0.24 per 10 000 population.10 In the Western Pacific Region, in 2018, the highest prevalence rate was found in Kiribati with 18.6 per 10 000 population, followed by the Marshall Islands with 11.0 per 10 000 population and the Federated States of Micronesia with 10.7 per 10 000 population (Table 3). The highest number of registered cases was reported in the Philippines with 4970 cases, followed by China with 970 cases and Papua New Guinea with 626 cases. Countries in which the prevalence rate was above elimination level included the following six: American Samoa, Kiribati, the Marshall Islands, the Federated States of Micronesia, Nauru and Tuvalu.

Fig. 2.

Prevalence rate of leprosy in the Western Pacific Region, 1983–2018 7 6

Cases registered per 10 000

5 4 3 2 1

Target

0 1983

1988

1993

1998

2003

2008

2013

2018

3.4 New case detection The new case detection rate for the Region fluctuated at a level above 0.7 per 100 000 population from 1986 to 1997, and dropped in 1993 to 2000 (Fig. 3). After 2000, the rate continued its downward movement, with an annual reduction rate of 4.8% for the last 18 years. After the adoption of the World Health Assembly resolution, the number of new cases detected decreased by 72.0%, from 14 991 cases in 1991 to 4193 cases in 2018. 10

Weekly epidemiological record. No. 35/36 Geneva: World Health Organization; 2019; 94: 389-412.

Part I. Epidemiological situation of leprosy in the Western Pacific Region

Fig. 3.

New case detection rate in the Western Pacific Region, 1983–2018 4

New cases per 100 000

0 1983

1988

1993

1998

2003

2008

2013

2018

Exponential fit: Recent annual change: −4.8 % Fig. 4 shows the geographical distribution of the new case detection rate in the Western Pacific Region in 2018. Countries with the highest case detection rate of more than 5 cases per 100 000 population were found in the Pacific, where there are many island countries and areas with a small population. Countries with a relatively high case detection rate of between 1 and 4.99 cases per 100 000 population were found in the Pacific islands as well as in Asia. In the Pacific islands, there appears to be a clear difference in distribution of new case detection rates by subregion: higher rates were found in Micronesia and Melanesia, whereas lower rates were found in Polynesia (countries with no data are usually those with no new cases).

Fig. 4.

Map showing new case detection rate in the Western Pacific Region, 2018

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Fig. 5 shows the new case detection rate in countries and areas that reported at least one new case in 2018. The countries with the three highest new case detection rates were Kiribati with 149 per 100 000 population, the Federated States of Micronesia with 113 per 100 000 population and the Marshall Islands with 101 per 100 000 population. These three countries were followed by other Pacific island countries and areas: American Samoa, Nauru, the Commonwealth of the Northern Mariana Islands, Palau, Papua New Guinea, Solomon Islands and Tuvalu. Of the 37 countries and areas in the Region, seven countries and areas (18.9%) did not report new leprosy cases in 2018.

Fig. 5.

New case detection rate for countries that reported at least one case in 2018

Kiribati Micronesia (Federated States of) Marshall Islands Nauru Tuvalu Solomon Islands Papua New Guinea Northern Mariana Islands (Commonwealth of the) Palau American Samoa Guam New Caledonia Samoa Philippines Vanuatu Fiji Lao People's Democratic Republic Tonga Cambodia Malaysia Brunei Darussalam Viet Nam Singapore China, Hong Kong SAR New Zealand China Australia Republic of Korea Japan

7.2 5.83 5.77 5.58 5.41 4.83 2.86 2.55 2.04 1.71 1.02 1.01 0.97 0.93 0.58 0.23 0.1 0.1 0.07 0.06 0.04 0.02 0.01 0.002

101

74.98 69.52

100

149.33

112.75

120

140

160

Detection per 100 000 Fig. 6 shows the new case detection data for the 10 countries with the most new cases in 2018. The highest number of new cases was reported in the Philippines with 2176 cases, followed by China with 521 cases and Papua New Guinea with 502 cases. These three are followed by Malaysia (182 cases), Kiribati (173 cases), Cambodia (151 cases), the Federated States of Micronesia (127 cases), Viet Nam (96 cases), the Lao People’s Democratic Republic (71 cases) and the Marshall Islands (59 cases). A comparison between the number and rate demonstrated that countries with a high number of new cases are not necessarily those with the highest rate. The countries with the three highest new case detection rates (Kiribati, the Marshall Islands and the Federated States of Micronesia) ranked relatively lower in the numbers.

Part I. Epidemiological situation of leprosy in the Western Pacific Region

Fig. 6.

New case detection rate and number for top 10 countries in the Western Pacific Region, 2018

New case detection rate (per 100 000)

Total number of new cases Philippines China Papua New Guinea Malaysia Kiribati Cambodia Micronesia (Federated States of) Viet Nam Lao People's Democratic Republic Marshall Islands

2.04 0.04 5.83 0.58

2176

521 502 182 173 151 127 96 71 59 0

149 0.93 113

0.1 1.01

101 0

500 1000 1500 2000 2500

100

150

200

Fig. 7 shows the scatter plot of the new case detection rate and numbers in 2018. The graph shows a difference in the epidemiological profile among different countries and areas. These fall into three groups: Pacific island countries and areas (PICs), low- and middle-income countries, and high-income countries. Low- and middle-income countries tend to appear in the figure with high numbers and intermediate rates, whereas high-income countries appear with low values for both number and rate. In the PICs, the number of new cases detected ranged from low to intermediate, while the rate ranged from intermediate to high. This suggested that the leprosy epidemiological profile in the Region may be influenced by geographical and economic factors. Addressing the leprosy burden in such a diverse epidemiological situation calls for country-specific strategies and approaches.

Fig. 7.

New case detection rate vs number, 2018

100

New case detection per 100 000

TUV

NRU

PLW

TON

MNP

KIR FSM

MHL

SLB

GUM WSM NCL VUT FIJI

PNG PHL LAO

KHM MYS

BRN 0.1

HKG 1

SGP

VNM 10

100

1000

Number of new cases Low & middle income

High income

PICs

Note: A log scale is used for both x and y axes. Country abbreviations can be found on page xii.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

The scatter plot of the level of incidence (new case detection rate) and annual change in the new case detection rate showed a clear positive correlation (Fig. 8). In general, the rate of annual reduction tends to be higher in lower endemic countries, while the number of new cases detected in highly endemic countries is still increasing. This analysis points to several important conclusions. First, strategies and programmatic priorities are diverse in the countries of the Region with clear distinctions between countries that have already entered into a steady declining stage of leprosy epidemiology and countries yet to reach that stage. Second, countries with increasing case detection trends, such as Kiribati, the Marshall Islands and the Federated States of Micronesia are probably the ones that are still expanding service coverage and require further investment in their programmatic response. Third, careful assessments are necessary for countries that are assumed to have lower- and middle-incidence status. For example, migration probably plays an important role in the epidemiology in Australia, Guam, New Caledonia and Singapore, and possibly Malaysia, where newly detected cases are on the rise. For countries with decreasing incidence, careful analyses, using subnational-level data, are needed to confirm whether the reduction in new case detection is associated with a true reduction of the disease burden.

Fig. 8.

Level of leprosy incidence and annual change GUM

KIR

Annual reduction / increase (%)

SLB

-5

FIJI

MYS

LAO

SGP

-15

FSM MHL

PNG

PHL

HKG CHN

-10

NCL

KHM

VNM

-20 0.1

100

New case detection per 100 000 (average) Low & middle income

High income

PICs

Note: New case detection rates (x-axis) were average rates calculated using data from 2009 to 2018. Annual changes (y-axis) were calculated using the historical data of new case detection rates from 2000 to 2018. A log scale is used for x-axes. Any incalculable or missing data for y-axis is deleted from the analysis. Country abbreviations can be found on page xii.

Trends for new case detection were compared among selected countries (Fig. 9 and Fig. 10). In numerical terms, the Philippines has maintained the highest leprosy caseload in terms of numbers for more than 20 years, and the number of new cases detected every year has fluctuated widely. The fluctuation may reflect the varying intensity of programme activities. China has seen a gradual decline in the number of new cases without notable fluctuation for the last 30 years. In Cambodia, the number peaked only in the 1990s and then have shown a steady decline since 2000. In contrast to these three countries, Malaysia, the Lao People’s Democratic Republic and Papua New Guinea have had a relatively stable caseload for the past 30 years. In terms of the rate, Papua New Guinea experienced the most rapid reduction during the 1980s. However, while the rate decreased compared to during the 1990s, it has been fluctuating in recent years, making it difficult to discern a trend. In Malaysia, the rate declined during the 1980s and 1990s, but it has increased

Part I. Epidemiological situation of leprosy in the Western Pacific Region

in recent years. China and Malaysia have seen a slow but steady reduction over the years (see country profiles). In Cambodia and the Philippines, the rate has steadily declined, in keeping with the change in case numbers.

Fig. 9.

Trend in number of new cases in top 6 countries in numbers, 1983–2018

8000

Philippines China Papua New Guinea Malaysia Lao People's Democratic Republic Cambodia

Number of new cases detected

7000 6000 5000 4000 3000 2000 1000 0 1980

1985

1990

1995

2000

2005

2010

2015

2020

Fig. 10. Trend in new case detection rate in top 6 countries in numbers, 1983–2018

Philippines China Papua New Guinea Malaysia Lao People's Democratic Republic Cambodia

New cases detected per 100 000 population

1980

1985

1990

1995

2000

2005

2010

2015

2020

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

3.5 Other key monitoring indicators Disease type Fig. 11 shows the distribution of MB and PB cases among total new cases detected in the Region from 1983 to 2018. Cases where the disease type was unknown were classified alongside PB cases. As data disaggregated by disease type were not available in some countries in the early years, changes in the MB rate in the early years mainly indicate changes in the reporting coverage. For example, in the Region, regular reporting on MB cases started in the Lao People’s Democratic Republic and the Philippines in 1983, China in 1986, Kiribati in 1988, Cambodia in 1990, the Marshall Islands in 1993, Viet Nam in 1992, and Malaysia, the Federated States of Micronesia and Papua New Guinea in 1994. It is important to note that a drop in the MB rate between 1990 and 1994 is due to missing MB data for the Philippines. Given that these countries carry most of the leprosy cases in the Region, the MB rate after 1995 could be considered as faithfully reflecting the distribution of MB and PB cases. The overall new case detection rate has steadily declined since 1997. The MB rate has followed, but more slowly when compared to the overall rate. During this period, the proportion of MB cases among total new cases increased from 69.0% to 82.8%. Different factors account for the increase in the proportion of MB cases. These include: • • • • •

declining stage of endemicity (more of the incidence cases will tend to be MB due to the longer incubation for MB);11, 12 demographics: an ageing population (MB is more likely to occur in the older age group, and is less frequently seen among children); start or expansion of the leprosy programme (undetected MB cases might have accumulated over the years); a shift from active to passive case detection; and wide definition of MB cases.13

The regional trend probably reflects the first and second factors, though others might also apply in some settings. Hence there is a need to assess individual country data according to country context and epidemiological profile.

Fig. 11. New case detection rate by disease type in the Western Pacific Region, 1983–2018

New cases per 100 000

0 1983

1988

1993 Total

11 12

1998

2003

Only MB

PB + Unknown

2008

2013

2018

Lee J, Kim JP, Nishikiori N, Fine PE. The decline of leprosy in the Republic of Korea; patterns and trends 1977-2013. Lepr Rev. 2015;86(4):316-27. Ishii N, Onoda M, Sugita Y, Tomoda M, Ozaki M. Survey of newly diagnosed leprosy patients in native and foreign residents of Japan. Int J Lepr Other Mycobact Dis. 2000;68(2):172-6. All factors were taken from the guidelines of the National Leprosy Eradication Programme (NLEP) in India, “Disability, MB and Child proportion – epidemiological significance and interpretation”.

Part I. Epidemiological situation of leprosy in the Western Pacific Region

Fig. 12 shows the proportion of MB cases among total new cases detected in countries and areas in the Region from 2014 to 2018. The regional average of the MB proportion was 80.7% during the five years. This was largely influenced by the data from the Philippines and China, which had the largest caseloads. Three high-burden countries in the Pacific – Kiribati, the Marshall Islands and the Federated States of Micronesia – had the lowest proportion of MB cases; median being 34.1% (interquartile range [IQR] 27.2–40.8]), 45.7% (IQR 42.1–51.6]) and 58.9% (IQR 50.6–65.9]), respectively. Countries that have active case finding activities tend to have more PB than MB cases.13 Besides the three PICs, Cambodia and Solomon Islands undertook active case finding activities during the last five years when funds were available, which may have resulted in the lower MB proportion. In contrast, countries and areas in the declining stage of endemicity, such as Brunei Darussalam, China and Hong Kong SAR (China) tend to have a higher MB proportion. In high-income countries where leprosy patients are predominantly of foreign origin, such as Australia, Japan and New Zealand, the MB proportion can vary as both MB and PB cases are detected among migrants from endemic countries.

Fig. 12. Proportion of MB leprosy cases by country and area, 2014–2018 100

MB %

ASM MNP PLW TOM GUM VUT WSM FJI NCL NRU SLB MHL TUV FSM KIR PYF PHL CHN VNM PNG LAO MYS KHM BRN HKG NZL KOR AUS MAC JON SGP WPR

Low & middle income

High income

PICs

Note: Data shown in median and 25th and 75th percentile. Country abbreviations can be found on page xii.

Leprosy among children A high rate and proportion of child leprosy cases may be a sign of active and recent transmission of the disease.13 Although data on child leprosy cases have been available in the Region since 1983, reports from all endemic countries have only been available since the late 1990s. In the Region, the number of child leprosy cases decreased by 60.2%, from 1240 cases in 1997 to 450 cases in 2018. Child cases represented 10.7% of total new cases in 2018. Fig. 13 shows the trend of a new case detection rate among children in the Region from 1983 to 2018. As compared to the overall new case detection rate (Fig. 3), no decline has been observed in the child rate for more than a decade.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Fig. 13. New case detection rate among children in the Western Pacific Region, 1983–2018 0.30

Number of new cases detected

0.25

0.20

0.15

0.10

0.05

0.00 1980

1985

1990

1995

2000

2005

2010

2015

2020

Fig. 14 shows the percentage of child leprosy cases by country and area in the Region from 2014 to 2018. The regional average of the child percentage was 10.8% during the five years. A higher percentage was observed in many PICs, with more than 20% in American Samoa, Kiribati, the Marshall Islands, the Federated States of Micronesia, New Caledonia, Solomon Islands and Tuvalu. In contrast, a lower percentage was found in low- and middle-income countries besides Papua New Guinea. Countries and areas that reported new cases from 2014 to 2018 but did not detect child cases were Australia, Brunei Darussalam, French Polynesia, Hong Kong SAR (China), Japan, Macao SAR (China), Nauru, the Commonwealth of Northern Mariana Islands, Palau, the Republic of Korea and Tonga.

Fig. 14. Proportion of child cases by country and area, 2014–2018 70 60

China %

50 40 30 20 10

NCL TUV FSM MHL KIR ASM SLB GUM WSM VUT FJI PYF NRU MNP PLW TON PNG KHM PHL LAO MYS VNM CHN NZL SGP AUS BRN HKG MAC JPN KOR WPR

0 Low & middle income

High income

PICs

Note: Data shown in median and 25th and 75th percentile. Country abbreviations can be found on page xii.

Part I. Epidemiological situation of leprosy in the Western Pacific Region

Fig. 15 (left) shows a scatter plot of the number of total new cases and new cases among children in countries and areas that reported at least one child case in 2018. In general, a tendency was observed whereby the more total new cases were detected, the more child cases were found. A difference in this distribution was seen between the PICs and other low- and middle-income countries, with the group of PICs showing a higher proportion of children. The new case detection rate among children was also higher in PICs (Fig. 15, right).

Fig. 15. Number of new cases, child vs all cases (left) and new case detection rate among children (right), 2018 PNG

Number of total new cases in children

100

PHL

KIR FSM MHL SLB

LAO

KHM MYS

CHN

TUV NCL

0.1

ASM

GUM FIJI

100

Number of total new cases Low & middle income High income

1000

KIR TUV FSM MHL NCL ASM PNG SLB GUM PHL LAO FIJI KHM MYS CHN

117 116 109 103 6.28 6.02 4.44 3.81 2.47 0.45 0.39 0.38 0.28 0.13 0.003 0

100

125

New cases per 100 000 child population PICs

Note: A log scale is used for both x and y axes (left). Country abbreviations can be found on page xii.

Leprosy among women Fig. 16 shows the proportion of females among new cases detected in the Region from 2014 to 2018. The regional average was 1.96, being skewed toward males (nearly 70% of new cases were male), which was higher than the global average of 1.51. In all countries and areas in the Region, except Hong Kong SAR (China) and Kiribati, there were more males than females among their new cases, that is the male–female ratio was greater than one. Hong Kong SAR (China) reported a majority of cases among immigrants from endemic countries who are also predominantly female. The median for the three endemic countries in the Pacific were 51.4% (IQR 46.4–52.9]) for Kiribati, 35.5% for the Federated States of Micronesia (IQR 31.4–36.9) and 34.6% (IQR 32.2–45.2) for the Marshall Islands. The latter two had relatively fewer female cases.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Fig. 16. Proportion of female cases by country and area, 2014–2018

100

Female %

60 50% 40

KIR MNP PLW PYF VUT ASM NCL SLB FSM MHL TUV GUM FJI WSM LAO PNG CHN VNM KHM MYS HKG MAC JPN AUS SGP KOR NZL WPR

0 Low & middle income

High income

PICs

Note: Data shown in median and 25th and 75th percentile. Country abbreviations can be found on page xii.

Grade 2 disability Fig. 17 shows the trend of new cases with Grade 2 disability in the Region from 1983 to 2018. Since 1997, the rate has decreased steadily over the years, which follows the reduction of the overall new case detection rate. In 1998, the Region achieved the global target of reducing the occurrence of new cases with Grade 2 disability to less than one case per million population. In 2018, the number of new cases with Grade 2 disability was 258, and the rate was 0.18 per million in the Region.

Fig. 17. New case detection rate for cases with Grade 2 disability 7 6

New cases per million

5 4 3 2 1

Target

0 1983

1988

1993

1998

2003

2008

2013

2018

Part I. Epidemiological situation of leprosy in the Western Pacific Region

In the Region, the proportion of cases with Grade 2 disability among total new cases has declined gradually with some fluctuations (Fig. 18). It fell from 15.4% in 1995 to 6.2% in 2018. The reduced percentage of cases with Grade 2 disability may indicate that cases have been detected earlier than previous years. However, careful assessment is required as the reduction in Grade 2 disability can also be attributable to a failure to assess all new cases for disability.

Fig. 18. Proportion of cases with Grade 2 disability

Percentage (%)

0 1983

1988

1993

1998

2003

2008

2013

2018

Global targets Following are the targets envisaged by the Global Leprosy Strategy 2016–2020:14 • •

zero Grade 2 disability among paediatric leprosy patients; and reduction of new leprosy cases with Grade 2 disabilities to less than one case per million population.

Table 4 showed the progress against Grade 2 disability among paediatric leprosy patients by 2018 compared to the 2016 level. However, as there was no active reporting on Grade 2 disability among paediatric patients before 2016, no valid comparison between 2016 and 2018 could be made. Only four countries (China, Kiribati, Papua New Guinea and Solomon Islands) completed reports in 2016. In 2018, 12 countries reported on Grade 2 disability in children, and it was found in nine cases among the total 4193 new cases detected in the Region (0.21%). These nine cases were from three countries: China, Kiribati and Papua New Guinea. Progress has been seen in the Region with nine countries achieving zero Grade 2 disability in child cases and 17 countries with no child case by 2018. It is of note that Viet Nam reported 96 new cases, among which they did not find any child case. While the situation seems close to achieving the global target in the Region, data on Grade 2 disability in children is still missing for the Philippines, which reports the highest number of new cases in the Region.

Global Leprosy Strategy 2016-2020: Accelerating towards a leprosy-free world. New Delhi: WHO Regional Office for South-East Asia; 2016 (https://apps.who.int/iris/ handle/10665/208824).

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Table 4. Progress against the global target of a zero Grade 2 disability among paediatric leprosy patients by 2020 compared to 2016 level (mid-term assessment) Country/area

Disability in children 2016 (number)

Total 2018 (number)

Disability in children 2018 (number)

China

672

521

Kiribati

218

173

Papua New Guinea

356

502

154

151

206

182

169

127

New Caledonia

Tuvalu

French Polynesia

Solomon Islands Cambodia Fiji Guam Malaysia Marshall Islands Micronesia (Federated States of)

Lao People’s Democratic Republic New Zealand Niue

1 721

2 176

Brunei Darussalam

China, Hong Kong SAR

China, Macao SAR

Cook Islands

Japan

Mongolia

Nauru

Northern Mariana Islands (Commonwealth of the)

Palau

Republic of Korea

Singapore

Tokelau

Tonga

Vanuatu

138

3 914

4193

Philippines Wallis and Futuna Australia

Samoa

Viet Nam Western Pacific Region NR: No report available, NA: Not applicable

Total 2016 (number)

Part I. Epidemiological situation of leprosy in the Western Pacific Region

Table 5 and Fig. 19 show the rates of new leprosy cases with Grade 2 disabilities per million population among the selected countries. In the Region, the rate decreased from 0.19 in 2016 to 0.13 in 2018. The rate increased in the Fiji, Malaysia, the Federated States of Micronesia and Solomon Islands, but otherwise a reduction was observed. A significant reduction was especially observed for Kiribati, where intensified case findings are taking place. Among these selected countries, Cambodia, Fiji, Kiribati, the Lao People’s Democratic Republic, the Federated States of Micronesia, Papua New Guinea and Solomon Islands have yet to achieve the global target of reducing the occurrence of new cases with Grade 2 disability to less than one case per million population.

Table 5.

Progress against the global target of reduction in new cases with Grade 2 disability to less than one case per million population by 2020 compared to 2016 level (midterm assessment)

Country/area Kiribati

Disability Disability 2016 2018 (rate per (rate per million) million)

Country/area

85.91

43.16

French Polynesia

26.63

Solomon Islands

3.27

4.6

Papua New Guinea

4.48

Lao People’s Democratic Republic

Disability Disability 2016 2018 (rate per (rate per million) million) 3.53

Guam

Japan

3.02

Marshall Islands

2.62

2.55

Mongolia

1.1

2.26

Nauru

Cambodia

1.87

1.35

New Caledonia

Philippines

0.65

0.48

New Zealand

Malaysia

0.22

0.32

Niue

Viet Nam

0.35

0.19

Northern Mariana Islands (Commonwealth of the)

China

0.11

0.07

Palau

Republic of Korea

0.02

Samoa

10.18

American Samoa

Singapore

0.16

Tokelau

Brunei Darussalam

Tonga

China, Hong Kong SAR

Tuvalu

China, Macao SAR

Vanuatu

Cook Islands

Wallis and Futuna

0.191

0.131

Micronesia (Federated States of)

Fiji

Australia

Westem Pacific Region

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability (Rate per million population)

Fig. 19. Change in Grade 2 disability rate from 2016 to 2018

Target

0.1

0.01

KIR

FSM

SLB

PNG LAO

FJI

KHM PHL MYS VNM CHN KOR

Disability 2016 (Rate per million)

AUS

PYF WSM WPR

Disability 2018 (Rate per million)

Note: A log scale is used for y axes. Country abbreviations can be found on page xii.

4. Legislation related to discrimination 4.1 Background In the past, leprosy was once feared as a highly contagious and debilitating disease.15 People affected by leprosy were forcibly quarantined under the law in isolated hospitals, sanatoria or leprosy colonies.16 In 1897, the First International Leprosy Congress held in Berlin recommended control by segregation of people with leprosy.17 This recommendation was reaffirmed during the Second International Leprosy Congress in Bergen in 1909, which further recommended the separation of children from parents who had leprosy.18 Following the international recommendations, governments enacted laws to legalize segregation of people affected by leprosy. India passed the Lepers Act in 1898, and Pakistan brought in the Lepers Act in the same year.17 South Africa enacted the Leprosy Repression Act in 1891.17 All these laws sanctioned the compulsory segregation of people affected by leprosy.17 The Bahamas, Egypt and Myanmar also had policies of compulsory segregation that were enforced by law.17 In addition to the enactment of these segregation laws and policies, provisions that discriminated against people affected by leprosy were introduced into other existing laws. For example, in India, under several personal laws, leprosy in either spouse constitutes a ground for divorce.19 The state-level beggary prevention laws allow for beggars and their dependents affected by leprosy to be detained or confined to leprosy asylums indefinitely.19 People with leprosy are liable to be disqualified from holding civic positions because they have leprosy.19 Furthermore, the right to travel on railways and the right to obtain a driving licence may be denied to peoples similarly affected.19 In Myanmar, prior to 1992,17 under the Inland Waterways Act, people with leprosy were required to report their condition to the captain of a vessel and request special 15 16 17

18 19

Hansen’s Disease (Leprosy) [website]. Atlanta: Centers for Disease Control and Prevention; 2016 (http://www.cdc.gov/leprosy/, accessed on 13 January 2016). International Federation of Anti-Leprosy Associations (ILEP). Press release for world leprosy day, 25th January 2015, London. Shigeki Sakamoto, “Requests Addressed To The Advisory Committee Stemming From Human Rights Council Resolutions: Elimination Of Discrimination Against Persons Affected By Leprosy And Their Family Members”, UN Human Rights Council, Doc. No. A/HRC/AC/3/CRP.2 (31 July, 2009) Skinsnes, supra note 11, p.226. Report No. 256, Eliminating discrimination against persons affected by leprosy. April 2015. Law Commission of India, Government of India.

Part I. Epidemiological situation of leprosy in the Western Pacific Region

accommodation. They were not permitted to handle food, machinery or clothing, or to use public wells and ponds.17 In Angola, people with leprosy were denied national identity cards.17 Even today, in some countries, people with leprosy and their families may be directly or indirectly discriminated against with respect to marriage, employment or the use of public places such as hotels, restaurants and means of transport.16 Furthermore, in many countries, having the disease can be cause to withhold entry visas and work permits, or even result in deportation under immigration laws. Despite the fact that leprosy was found not to be particularly contagious and is now curable with multidrug therapy, such laws continue to cause needless discrimination against people affected by leprosy and their family members, and in some settings, may be violations of fundamental human rights.

4.2 Rationale In December 2010, the United Nations General Assembly adopted a resolution that called for the elimination of discrimination against people affected by leprosy and their family members. The resolution reaffirmed that: Persons affected by leprosy and their family members should be treated as individuals with dignity and are entitled to all human rights and fundamental freedoms under customary international law, relevant conventions and national constitutions and laws.20 The resolution introduced a set of principles and guidelines for governments and other organizations. One of the guidelines included: (States should) take all appropriate legislative and administrative measures to modify, repeal or abolish existing laws, rules, policies, regulations, customs and practices that discriminate directly or indirectly against persons affected by leprosy and their family members, or that forcefully or compulsorily segregate and isolate persons on the grounds of leprosy in the context of such discrimination.21 In response to these international guidelines, in 2015, the Law Commission of India conducted a comprehensive review of domestic laws that could either be repealed or that needed amending, and submitted its report and recommendations to the Minister for Law and Justice for further action.19 The International Federation of Anti-Leprosy Associations has also been conducting a review of legislation in 63 countries. As part of the preparation for this epidemiological report, the WHO Regional Office for the Western Pacific conducted a regional review of policy and legislation related to discrimination against people affected by leprosy. A structured questionnaire was sent to the leprosy focal points in 36 countries and areas of the Region, the aim being to ascertain whether the country had, at present or in the past, laws that might directly or indirectly discriminate against people affected by leprosy.22 The respondents to the questionnaire included 19 countries (53%): Australia, Brunei Darussalam, Cambodia, China, Hong Kong SAR (China), Japan, the Lao People’s Democratic Republic, Macao SAR (China), Malaysia, the Federated States of Micronesia, Mongolia, New Zealand, the Commonwealth of the Northern Mariana Islands, Palau, Papua New Guinea, Singapore, Solomon Islands, Tuvalu and Viet Nam. The Regional Office also reviewed an unpublished report concerning the Philippines,23 and literature and law databases for some countries that were available online.

20 21

22 23

UN resolution A/RES/65/215, Elimination of discrimination against persons affected by leprosy and their family members. UN Human Rights Council, Advisory Committee, A/HRC/AC/5/2, Revised principles and guidelines for the elimination of discrimination against persons affected by leprosy and their family members. Pitcairn Islands was not included due to its small population size. Belen Dofitas, “An overview of Philippine laws and bills on leprosy - A report submitted to the World Health Organization Western Pacific Regional Office”, December 2015.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Zero countries with legislation on leprosy allowing discrimination is one of the targets to be achieved under the Global Leprosy Strategy 2016–2020,14 and this review will help establish a basis for evaluating the achievement of this target in the Region.

4.3 Segregation law and policy In the Western Pacific Region, countries and areas that had leprosy segregation laws or policies in the past include Australia, China, Hong Kong SAR (China), Japan, Macao SAR (China), Malaysia, New Zealand, the Philippines, the Republic of Korea, Singapore and Solomon Islands. All of these countries abolished their segregation law or policy at some date ranging from the 1940s in New Zealand to 1996 in Japan. In Australia, Queensland’s Leprosy Act of 1892 promoted the detention and isolation of people with leprosy. An uninhabited offshore island was selected as a leper colony that was exclusively for indigenous people.24 In Singapore, compulsory segregation of people affected by leprosy was enforced in 1897. In Japan, the Leprosy Prevention laws permitted the segregation of patients in sanatoria, where forced abortions and sterilization were common.25 In the Republic of Korea, the compulsory segregation law for people affected by leprosy was abolished in 1961.17 In Malaysia, the Leprosy Act was enacted by the former British colonial government. In Hong Kong SAR (China), the Lepers Ordinance was enacted to sanction segregation of people affected by leprosy in 1910.26

4.4 Immigration laws and policies In the Western Pacific Region, the issuance of an entry visa for people who have leprosy may be affected under immigration laws and policies in Brunei Darussalam, Cambodia, Malaysia, the Philippines, Solomon Islands and Tuvalu, and possibly other countries. Of them, Malaysia, the Philippines, Solomon Islands and Tuvalu may refuse a visa to a person with the untreated active disease, while Brunei Darussalam and Cambodia may do so for a person with the disease under treatment. However, the scope and rigidity of such regulations seem to vary widely depending on the types of visa, purpose of entry and duration of the intended stay. In Brunei Darussalam, a foreign-born person found to have leprosy within the country is subject to deportation to their home county. A similar deportation policy also exists in Malaysia. In Australia, a “health undertaking” can be requested from a visa applicant who has leprosy, who must then agree to be placed under the supervision of a local health authority for treatment or investigation. In the Federated States of Micronesia, a foreign-born person found to have leprosy within the country is not permitted to work until he or she completes the first two weeks of treatment with a treatment partner. In all responding countries and areas, entry visas and work permits were not withheld for people who had leprosy but had completed MDT.

4.5 Other laws In Singapore, people affected by leprosy were banned from using public transport under the Railway Act of 1906.17 A breach of this regulation was punishable by a fine not exceeding 500 Singapore dollars and an order to pay for the disinfection of the carriage.27 In Malaysia, a woman married in accordance with hukum syarak (the traditional Islamic law) can obtain the dissolution of marriage with her husband on the basis of leprosy under the Islamic Family Law of 1984.28 In the Philippines, under the Revised Rules of Courts that are currently in force, a hospitalized person who has leprosy is included in a list of legally “incompetent” people for whom the guardianship is to be appointed by a court.23 This may infringe on their rights to determine their own medical care or even the right to administer their own properties. 24 25

26 27 28

Genever, Geoffrey. Queensland’s Black Leper Colony. Queensland Review, Vol. 15, No. 2, 2008: 59-68. Jensen, M. and Jolly, M (eds.). We Shall Bear Witness: Life Narratives and Human Rights (Wisconsin Studies in Autobiography). Madison: University of Wisconsin Press; 2014. LEPERS ORDINANCE, 1910. Hong Kong: The Historical Laws of Hong Kong Online; 2016 (http://oelawhk.lib.hku.hk/items/show/1246, accessed on 19 February 2016). Railway Act (Chapter 263). Singapore: Singapore Statutes Online; 2020 (https://sso.agc.gov.sg/Act/RA1905, accessed on 17 January 2020). Laws of Malaysia Act 303 Islamic Family Law (Federal Territories) Act 1984. Kuala Lumpur: The Commissioner of Law Revision; 2006 (http://www.somalilandlaw.com/ Malaysian_Islamic_Family_Law_1984.pdf, accessed on 11 December 2016).

Part I. Epidemiological situation of leprosy in the Western Pacific Region

4.6 Limitations and way forward This regional review has several limitations. First, some of the relevant laws and rules could have been omitted due to limitations in the methodology. All respondents of our survey are leprosy focal persons in the health ministries who provided information, with or without consultation with other ministries. Laws and legal rules under the purview of other ministries may have been insufficiently examined. Second, a structured questionnaire with multiple-choice questions could have restricted the flexibility of the response, and therefore some legal domains may not have been captured in the questionnaire. Third, the relevant legal documents and information might not be available or accessible as they tend to date back a long time. Despite these limitations, the review demonstrated that laws that directly or indirectly discriminated against people with leprosy and their family members were in force in the past in some countries and areas of the Western Pacific Region, and some seem to be applicable even today, regardless of whether they are enforced. To repeal or amend discriminatory laws requires a more rigorous review at the country level. Although parliamentary procedures to repeal or amend legislation may vary from one country to another, a situation assessment, with a review of domestic laws by local jurists and leprosy experts, would be a necessary foundation for initiating a wider policy discussion. Learning from successful experiences reported in many parts of the world, all countries and areas in the Region are encouraged to work towards eliminating legal discrimination against people affected by leprosy and their family members.

Part II. Country profiles

AMERICAN SAMOA Population 55 465 (2018)

Background • • • • •

Leprosy has been endemic for many years. Staff at health centres refer suspected cases to the Department of Health. MDT has been administered since 1984. Case finding is mainly passive. Contacts of active cases are listed for systematic examination, but compliance with examination is partial.

Elimination target •

Reached in 1996 (less than 10 prevalent cases, which WHO considers as elimination for countries with a small population). However, the elimination level has not been sustained as more than 10 prevalent cases were reported in 2009 and 2012.

Epidemiology • • •

The prevalence rate has fluctuated between 0.7 and 2.8 per 10 000 population since 1995. The new case detection rate declined between 1983 and 1996, whereas over the last two decades the rate has fluctuated between 0 and 17.6 per 100 000 population. The number of new cases with Grade 2 disability is reported as less than two each year since 1983.

Post-elimination activities •

The disease is being closely monitored, and efforts are being made to sustain leprosy awareness in the community and among health staff.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in American Leprosy profile Samoa in American Samoa New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate 15 10 5 0

Target

1983

1988

1993

1998

2003

2008

2013

50 40 30 20 10 0

2018

1983

1988

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

2018

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

Percentage (%) 1988

1993

1998

2003

2008

2013

2018

1983

1988

Percentage (%) 1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

Percentage (%)

1993

2008

60 50 40 30 20 10 0

2018

120 100 80 60 40 20 0 1988

2003

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

Proportion of cases with Grade 2 disability

1983

1998

Proportion of child cases

Target

1983

1993

New cases with Grade 2 disability (Rate) New cases per million

2013

Number of child cases

Number

Number of cases with Grade 2 disability

2008

120 100 80 60 40 20 0

1983

60 50 40 30 20 10 0

2003

Proportion of MB cases

50 40 30 20 10 0

1998

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

60 50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : American Samoa

1983

1984

1985

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (‘000)

Leprosy indicators in American Samoa

41.48

60.0

20.0

0.0

0.00

22.93

55.6

11.1

22.2

50.96

1986

26.94

45.5

27.3

0.0

0.00

1987

30.62

30.8

23.1

7.7

23.56

1988

15.89

1989

13.16

83.3

0.0

33.3

43.87

1990

13.18

19.13

88.9

11.1

0.0

0.00

1991

10.13

18.60

88.9

0.0

0.00

1992

14.10

28.6

14.3

0.0

0.00

1993

4.13

7.88

100.0

0.0

0.00

1995

2.46

7.56

50.0

0.0

0.00

1996

1.30

5.57

66.7

0.0

0.00

1997

1.46

10.94

83.3

33.3

0.0

0.00

1998

1.44

10.76

83.3

0.0

0.00

1999

1.59

17.65

50.0

20.0

0.0

0.00

2000

1.74

3.47

100.0

50.0

0.0

0.00

2001

1.36

8.53

100.0

0.0

0.00

2002

1.01

0.00

2003

1.32

3.29

50.0

0.0

0.00

2004

0.65

4.85

66.7

0.0

0.00

2005

2006

0.94

9.37

2009

2.38

4.46

100.0

0.0

33.3

0.0

0.00

2010

0.88

0.00

Inf

0.00

2011

1.15

5.75

100.0

0.0

25.0

0.0

0.00

2012

1.98

11.32

100.0

0.0

12.5

0.0

0.00

2013

0.70

1.39

0.0

100.0

13.92

2014

0.82

5.48

100.0

25.0

50.0

0.0

0.00

2016

1.26

12.58

100.0

14.3

42.9

0.0

0.00

2017

0.00

2018

1.44

5.41

100.0

33.3

0.0

0.00

1994

2007 2008

2015

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

AUSTRALIA Population 24 898 152 (2018)

Background • • • •

•

Cases have been treated with MDT since 1982. Locally acquired infections are uncommon and have mostly affected the indigenous population. The majority of Australia’s leprosy notifications are acquired overseas in leprosy-endemic regions. There is no national control policy and no national register. However, leprosy is a notifiable disease in Australia, and the Australian Government holds a national register of all new cases for surveillance purposes only. Case finding is mainly passive, with occasional community surveys in endemic pockets and contract surveys.

Elimination target •

Australia has already achieved the elimination targets but continues to record a small number of cases each year, mostly in migrants who initially acquired their infection overseas in a leprosy-endemic region.

Epidemiology • •

The number of new cases reported annually has slightly increased from 2010 to 2018 as compared to 2000 to 2009, although the reporting is incomplete. The new case detection rate has been stable, being lower than 0.1 per 100 000 population since 1990.

Post-elimination activities •

Not applicable.

Part II. Country profiles : Australia

Leprosy profile in Australia

Leprosy profile in Australia New case detection rate

1.0 0.8 0.6 0.4 0.2 0.0

New cases per 100 000

Cases registered per 10 000

Prevalence rate

1983

1988

1993

1998

2003

2008

2013

1.0 0.8 0.6 0.4 0.2 0.0

2018

1983

1988

Proportion of MB cases

1.0 0.8 0.6 0.4 0.2 0.0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988 1993 1998 Only MB Total

120 100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

20 10

Percentage (%)

New cases per million

0.15 0.10 0.05 0.00 1998

2003

2008

2013

1983

1988

1998

2003

2008

2013

Percentage (%)

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

1993

2018

30 25 20 15 10 5 0

2018

30 25 20 15 10 5 0 1988

2013

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

Proportion of cases with Grade 2 disability

1983

2008

Proportion of child cases

0.20

1993

2003

New cases with Grade 2 disability (Rate)

1988

1998

20 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983

1993

Number of child cases

Number

Number of cases with Grade 2 disability

1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: 1.6 %

2018

100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Australia

1984

15 549

0.18

1985

15 791

0.24

1986

16 047

0.17

1987

16 315

0.18

1988

16 586

0.12

17 096

0.04

0.09

1994

17 922

0.01

0.00

1995

18 118

0.00

0.04

14.3

1996

18 320

0.06

18.2

1997

18 525

0.08

20.0

26.7

1998

18 735

0.01

1999

18 948

0.00

0.03

16.7

2000

19 164

0.00

0.03

60.0

80.0

2001

19 382

0.02

25.0

2002

19 604

0.00

0.04

12.5

0.0

37.5

0.0

0.00

2003

19 840

0.00

0.05

22.2

0.0

66.7

11.1

0.05

2004

20 104

0.00

0.03

66.7

0.0

66.7

16.7

0.05

2005

20 404

0.05

60.0

2006

20 744

0.04

11.1

77.8

2007

21 120

0.06

53.8

0.0

23.1

15.4

0.09

2008

21 514

0.00

0.05

9.1

0.0

27.3

9.1

0.05

2009

21 902

0.02

80.0

20.0

60.0

20.0

0.05

2010

22 268

0.04

80.0

10.0

20.0

0.09

2011

22 606

0.04

77.8

0.0

33.3

22.2

0.09

2012

22 919

0.03

50.0

0.0

25.0

0.09

2013

23 214

0.06

71.4

0.0

42.9

7.1

0.04

2014

23 503

0.04

77.8

0.0

44.4

11.1

0.04

2015

23 793

0.00

0.05

30.8

0.0

38.5

15.4

0.08

2016

24 263

0.01

0.08

79.0

0.0

15.8

21.1

0.16

2017

24 585

0.01

0.04

70.0

0.0

10.0

20.0

0.08

2018

24 898

0.00

0.02

100.0

0.0

50.0

0.0

0.00

1989 1990 1991 1992 1993

Part II. Country profiles : Brunei Darussalam

BRUNEI DARUSSALAM Population 428 963 (2018)

Background • • •

Leprosy is not a public health problem. However, since 1985, a few cases have been reported almost every year. The case finding strategy is passive. Clinical management has been provided by the Dermatology Department, and public health management has been provided by the Disease Control Division.

Elimination target •

Not applicable

Epidemiology • • •

The prevalence rate has been less than 0.21 per 10 000 population since 1986. The number of new cases has been reported as less than four since 1986. No child cases or cases with Grade 2 disability have ever been reported.

Post-elimination activities •

Not applicable.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in Brunei Darussalam New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate 1.0 0.8 0.6 0.4 0.2 0.0 1983

1988

1993

1998

2003

2008

2013

1.5 1.0 0.5 0.0

2018

1983

1988

1.5 1.0 0.5 0.0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

4 2

2013

2018

1993

1998

2003

2008

2013

2018

2 1 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

Proportion of child cases Percentage (%)

New cases per million

0.10 0.08 0.06 0.04 0.02 0.00 1983

1988

1993

1998

2003

2008

2013

10 8 6 4 2 0

2018

1983

1988

Proportion of cases with Grade 2 disability 10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

Percentage (%)

2008

Number of child cases

2003

250 200 150 100 50 0

Number of cases with Grade 2 disability

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

120 100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Brunei Darussalam

1986

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Brunei Darussalam

229

0.13

0.44

252

0.12

0.00

1993

274

0.11

1.46

50.0

1994

282

0.21

1.42

100.0

0.0

0.00

1995

290

0.21

0.35

100.0

1996

297

0.10

0.34

0.0

0.00

1997

305

0.20

0.33

200.0

0.0

0.00

1999

320

0.03

0.31

100.0

0.0

0.00

2000

327

0.00

2001

334

0.15

1.20

125.0

0.0

25.0

0.0

0.00

2002

342

0.03

0.29

0.0

0.00

2003

349

0.06

0.57

0.0

50.0

0.0

0.00

363

0.03

0.83

33.3

2008

385

0.00

0.52

100.0

0.0

50.0

0.0

0.00

2009

392

0.05

0.51

100.0

0.0

0.00

2010

399

0.08

0.75

100.0

0.0

33.3

0.0

0.00

2011

406

0.05

0.00

2012

413

0.02

0.48

100.0

0.0

0.00

2013

420

0.02

0.00

2014

427

0.00

0.23

100.0

0.0

0.00

2015

433

0.00

2016

420

0.00

2017

424

0.00

0.46

100.0

0.0

0.00

2018

429

0.02

0.23

100.0

0.0

0.00

1987 1988 1989 1990 1991 1992

1998

2004 2005 2006 2007

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

CAMBODIA Population 16 249 792 (2018)

Background • • •

• •

Leprosy has been endemic for many decades. There was an estimated backlog of 10 000 cases in 1995. However, most of the backlog and new cases that were detected were treated by 1998. MDT treatment has been used since 1984. Case detection activities were intensified from 1995 through special projects such as leprosy elimination campaigns (LECs) and special action projects for elimination of leprosy (SAPELs) covering the whole country. Leprosy control activities were integrated with the National Tuberculosis Control Programme in 1996. Contact tracing, along with an information, education and communication (IEC) campaign was conducted during from 2011 to 2018.

Elimination target • • •

Achieved by the end of 1998 with a prevalence rate of 0.86 per 10 000 population at the national level. Subnational elimination was achieved in all the provinces except two by the end of 2001. District-level elimination is within grasp.

Epidemiology • • • •

Prevalence and new case detection rates increased steeply from 1993 to 1997 corresponding to the intensified case finding activities. After the period of intensified activities, prevalence and new case detection rates sharply dropped over a few years and now show a gradual declining trend without any notable increase. The proportion of child cases among total cases has been stable at around 10% since 1993. The proportion of cases with Grade 2 disability was highest in 1993 at 24.6%, and they have been declining.

Post-elimination activities • •

A pilot post-elimination surveillance system based on the protocol developed by the WHO Regional Office for the Western Pacific has been operating in selected provinces since 2000. IEC activities are being carried out, including refresher training, intensified case detection activities in high-endemic pockets, prevention and management of disabilities, and the use of geographic information systems.

Part II. Country profiles : Cambodia

Leprosy profile in Cambodia

3.0 2.5 2.0 1.5 1.0 0.5 0.0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

25 20 15 10 5 0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: −9.3 % Proportion of MB cases

25 20 15 10 5 0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988 1993 1998 Only MB Total

100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number of cases with Grade 2 disability

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

Percentage (%)

New cases per million

2008

2013

2018

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child Proportion of child cases

Target

1983

1988

1993

1998

2003

2008

2013

20 15 10 5 0

2018

1983

1988

Proportion of cases with Grade 2 disability 30 25 20 15 10 5 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

Percentage (%)

2003

Number

2500 2000 1500 1000 500 0

New cases with Grade 2 disability (Rate) 50 40 30 20 10 0

1998

Number of child cases

Number

2500 2000 1500 1000 500 0

1993

2018

50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Cambodia

1985

7 743

649

0.84

704

9.09

1986

7 990

742

0.93

549

6.87

1987

8 228

1 145

1.39

545

6.62

78.2

9.0

17.1

11.30

1988

8 467

1 334

1.58

706

8.34

1989

8 724

1 170

1.34

789

9.04

1990

9 532

1 728

1.81

581

6.10

74.5

9.3

14.5

8.81

1991

9 868

1 669

1.69

415

4.21

63.6

7.2

13.5

5.67

1992

10 206

1 627

1.59

617

6.05

62.1

17.7

10.5

6.37

1993

10 539

2 038

1.93

945

8.97

64.6

24.6

22.01

1994

10 862

2 461

2.27

1 644

15.14

55.4

9.0

20.7

31.30

1995

11 169

2 886

2.58

2 219

19.87

54.3

9.6

20.9

41.54

1996

11 459

2 960

2.58

2 404

20.98

50.1

10.8

16.4

34.47

1997

11 731

1 921

1.64

2 438

20.78

51.8

11.0

17.0

35.38

1998

11 986

984

0.82

1 609

13.42

49.0

9.5

9.1

12.18

1999

12 224

584

0.48

790

6.46

53.5

13.3

9.7

6.30

2000

12 447

582

0.47

747

6.00

66.7

10.4

8.2

4.90

2001

12 654

526

0.42

634

5.01

62.8

11.2

29.7

8.2

4.11

2002

12 845

588

0.46

740

5.76

66.1

8.5

25.0

8.2

4.75

2003

13 024

409

0.31

509

3.91

68.4

9.2

26.5

14.5

5.68

2004

13 194

370

0.28

460

3.49

68.3

11.1

30.7

14.8

5.15

2005

13 358

348

0.26

429

3.21

69.7

9.1

28.2

14.5

4.64

2006

13 516

305

0.23

376

2.78

74.2

9.8

27.9

16.0

4.44

2007

13 670

257

0.19

315

2.30

67.3

7.9

28.3

11.4

2.63

2008

13 823

242

0.18

306

2.21

71.6

6.9

27.8

13.1

2.89

2009

13 978

283

0.20

351

2.51

69.5

7.7

29.9

10.3

2.58

2010

14 138

236

0.17

262

1.85

70.6

8.4

21.4

9.9

1.84

2011

14 305

255

0.18

314

2.20

59.6

8.3

30.3

6.1

1.33

2012

14 478

353

0.24

475

3.28

54.5

9.7

39.8

9.7

3.18

2013

14 656

284

0.19

373

2.55

52.3

8.6

30.8

4.6

1.16

2014

14 836

284

0.19

310

2.09

38.7

6.1

25.8

2.3

0.47

2015

2016

15 766

0.00

154

0.96

69.5

7.8

22.7

19.5

1.87

2017

16 009

120

0.07

137

0.84

56.9

4.4

30.7

13.1

1.11

2018

16 250

0.04

151

0.93

56.3

9.3

39.7

14.6

1.35

Part II. Country profiles : China

CHINA Population 1 427 647 786 (2018)

Background • •

• • •

Leprosy has long been endemic – in 1950 there were an estimated 500 000 cases. Leprosy services have been delivered under various models, including ones combined with dermatology, integrated with the general health system or combined with tuberculosis (TB), sexually transmitted infections and HIV services. MDT was introduced in 1982 in Yangzhou Prefecture in Jiangsu Province and in Sichuan and Yunnan provinces. MDT was introduced in 1985, and nationwide implementation began in 1987. Tremendous progress has been made in bringing the disease under control, and the problem is now limited to a few pockets in several provinces of south-west China. Case finding is passive in eastern China at general hospital skin clinics or dermatology departments, but in some counties in south-west China where leprosy is more prevalent, active case finding has been performed in rural areas.

Elimination target •

•

Leprosy has been eliminated as a public health problem. The national-level elimination target was met in 1982. Subnational elimination was accomplished at the provincial, municipal and autonomous region level by 1992. At the end of 2000, the prevalence rate exceeded 1 per 10 000 population in 48 counties (out of some 2500 counties) in Hunan, Sichuan, Tibet and Yunnan provinces. By the end of 2014, only nine counties in Sichuan and Yunnan had a prevalence rate of more than 1 per 10 000 population.

Epidemiology • •

•

The prevalence rate has decreased considerably in the late 1980s and early 1990s, and it has been less than 0.1 per 10 000 population since 1992. The number of new cases has declined over the last three decades, falling from nearly 5 000 cases in 1986 to less than 1 000 cases since 2013. Accordingly, the new case detection rate decreased from 0.5 to less than 0.1 per 100 000 population in the same period. The proportion of MB cases among total cases has increased over the years, while the proportion of cases with Grade 2 disability has remained stable at around 20%.

Post-elimination activities • • •

Efforts are being made to eliminate remaining pockets of infection located mostly in hard-toaccess areas and communities, through special campaigns. There are an estimated 120 000 individuals disabled due to leprosy and efforts are being made to rehabilitate them. The programme has emphasized the maintenance of leprosy expertise both at the national and subnational levels.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in China

1.2 1.0 0.8 0.6 0.4 0.2 0.0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate Target

1983

1988

1993

1998

2003

2008

2013

1.0 0.8 0.6 0.4 0.2 0.0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: −6.8 % Proportion of MB cases

1.0 0.8 0.6 0.4 0.2 0.0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988 1993 1998 Only MB Total

120 100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number of cases with Grade 2 disability

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

Percentage (%)

New cases per million

2008

2013

2018

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child Proportion of child cases

0.6 0.4 0.2 0.0 1983

1988

1993

1998

2003

2008

2013

10 8 6 4 2 0

2018

1983

1988

Proportion of cases with Grade 2 disability 30 20 10 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

Percentage (%)

2003

Number

5000 4000 3000 2000 1000 0

New cases with Grade 2 disability (Rate)

1998

Number of child cases

Number

5000 4000 3000 2000 1000 0

1993

2018

40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : China

Disability per million

Detection per 100 000

1986

1 071 835

4 945

0.46

1987

1 092 647

70 000

0.64

4 042

0.37

57.0

1988

1 114 162

55 240

0.50

3 837

0.34

60.0

1989

1 135 128

40 000

0.35

3 303

0.29

74.0

3.0

1990

1 145 195

30 000

0.26

3 345

0.29

63.0

1991

1 160 800

20 003

0.17

3 400

0.29

53.0

3.0

1992

1 175 230

8 460

0.07

2 728

0.23

57.0

3.0

1993

1 188 688

6 055

0.05

2 191

0.18

66.0

3.0

24.0

0.56

1994

1 201 523

5 655

0.05

2 109

0.18

66.0

3.0

24.0

0.44

1995

1 213 987

4 833

0.04

1 895

0.16

69.0

3.0

21.0

0.37

1996

1 226 134

4 474

0.04

1 845

0.15

68.0

3.0

23.4

0.36

1997

1 237 850

4 045

0.03

1 854

0.15

69.2

3.4

10.4

0.16

1998

1 249 020

4 087

0.03

2 051

0.16

81.3

4.3

21.3

0.32

1999

1 259 477

4 029

0.03

1 692

0.13

77.8

5.4

20.5

0.34

2000

1 269 117

3 646

0.03

1 603

0.13

79.6

3.4

22.0

0.30

2001

1 277 904

3 510

0.03

1 726

0.14

82.3

3.6

21.1

0.27

2002

1 285 934

3 263

0.03

1 646

0.13

87.5

2.7

23.4

0.30

2003

1 293 397

3 261

0.03

1 404

0.11

86.5

3.1

21.2

0.23

2004

1 300 552

3 203

0.02

1 499

0.12

87.9

3.1

32.4

23.5

0.27

2005

1 307 593

3 171

0.02

1 658

0.13

89.1

2.1

30.8

21.3

0.27

2006

1 314 581

3 264

0.02

1 516

0.12

87.9

2.8

33.4

22.8

0.26

2007

1 321 482

3 196

0.02

1 526

0.12

84.9

2.2

32.2

22.7

0.26

2008

1 328 276

3 388

0.03

1 614

0.12

86.9

2.5

30.2

22.1

0.27

2009

1 334 909

3 332

0.02

1 597

0.12

84.3

2.4

32.0

22.8

0.27

2010

1 341 335

2 886

0.02

1 324

0.10

84.9

2.9

31.6

22.5

0.22

2011

1 347 565

2 468

0.02

1 144

0.08

82.3

2.5

31.9

27.0

0.23

2012

1 353 601

2 331

0.02

1 206

0.09

80.8

2.4

29.8

28.7

0.26

2013

1 359 368

1 908

0.01

924

0.07

86.6

1.5

33.3

20.3

0.14

2014

1 364 773

1 601

0.01

823

0.06

88.5

1.7

32.0

20.0

0.12

2015

1 369 743

1 353

0.01

678

0.05

88.2

2.9

30.1

18.6

0.09

2016

1 414 049

0.00

672

0.05

89.0

2.8

32.0

22.0

0.11

2017

1 421 022

1 177

0.01

634

0.04

91.8

1.4

34.2

20.0

0.09

2018

1 427 648

970

0.01

521

0.04

89.4

1.3

36.9

19.0

0.07

Disability %

0.95

Female %

100 000

Child %

1 052 622

MB %

Registered cases

1985

New cases

Year

Population (000)

Prevalence per 10 000

Leprosy indicators in China

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

CHINA, HONG KONG SAR Population 7 371 730 (2018)

Background • • • • • •

The programme is part of the Social Hygiene Service of the Department of Health. Leprosy cases are mainly managed as outpatients with MDT. No other treatment regimens are used currently. Contacts of new cases are screened after voluntary referral by the index case. Treatment is free of charge and cases include active as well as treated cases. New cases of leprosy detected by other units are also referred to the unit. There is a call-back system for leprosy patients who fall outside the follow-up.

Elimination target •

Leprosy is no longer a public health problem.

Epidemiology • • •

Both the prevalence and new case detection rate have been low since 1991. The number of new cases has gradually decreased over time. However, three to seven new cases have been reported every year since 2002. New cases are mainly foreign-origin cases from Asian countries such as China, Indonesia, Nepal and the Philippines.

Post-elimination activities •

Nothing specific.

Part II. Country profiles : China, Hong Kong SAR

Leprosy profile in China, Hong Kong SAR New case detection rate

1.0 0.8 0.6 0.4 0.2 0.0

New cases per 100 000

Cases registered per 10 000

Prevalence rate

1983

1988

1993

1998

2003

2008

2013

1.0 0.8 0.6 0.4 0.2 0.0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: −5.3 % Proportion of MB cases

1.0 0.8 0.6 0.4 0.2 0.0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988

1993

1998 Only MB

Total

2003

2008

2013

120 100 80 60 40 20 0

2018

1983

1988

20 10

2003

2008

2013

2018

1983

1988

New cases per million Percentage (%)

Percentage (%) 1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

50 40 30 20 10 0 1988

Child

12 10 8 6 4 2 0

Proportion of cases with Grade 2 disability

1983

2018

1983 1988 1993 1998 2003 2008 2013 2018 Adult

Percentage (%) 1998

2013

Proportion of child cases

1.0 0.8 0.6 0.4 0.2 0.0 1993

2008

New cases with Grade 2 disability (Rate)

1988

2003

20 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983

1998

Number of child cases

Number

Number of cases with Grade 2 disability

1993

PB + Unknown

2018

120 100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in China, Hong Kong SAR

1983

5 291

0.72

71.1

1984

5 350

0.60

40.6

1985

5 415

0.59

59.4

1986

5 487

0.53

51.7

1987

5 565

0.38

52.4

1988

5 645

0.39

63.6

1989

5 722

0.45

84.6

1990

5 794

0.54

54.8

1991

5 857

0.11

0.44

69.2

1992

5 914

0.08

0.34

65.0

20.0

0.68

1993

5 974

0.52

74.2

0.0

45.2

1994

6 048

0.35

61.9

4.8

38.1

1995

6 144

0.24

80.0

6.7

40.0

33.3

0.81

1996

6 268

0.07

0.13

50.0

0.0

50.0

12.5

0.16

1997

6 414

0.08

0.17

27.3

0.0

36.4

0.0

0.00

1998

6 564

0.09

0.17

81.8

0.0

72.7

9.1

0.15

1999

6 693

0.05

0.21

42.9

0.0

21.4

0.0

0.00

2000

6 783

0.05

0.16

54.5

0.0

36.4

0.0

0.00

2001

6 829

0.05

0.15

40.0

10.0

20.0

30.0

0.44

2002

6 837

0.06

0.09

66.7

0.0

66.7

16.7

0.15

2003

6 822

0.06

0.10

42.9

0.0

71.4

14.3

0.15

2004

6 808

0.05

0.09

83.3

0.0

33.3

16.7

0.15

2005

6 810

0.05

0.06

100.0

0.0

75.0

0.0

0.00

2006

6 833

0.04

0.09

100.0

0.0

50.0

16.7

0.15

2007

6 873

0.04

0.03

0.0

50.0

0.0

0.00

2008

6 926

0.03

0.07

40.0

0.0

20.0

0.0

0.00

2009

6 988

0.03

0.06

40.0

0.0

20.0

0.0

0.00

2010

7 053

0.03

0.04

100.0

0.0

100.0

0.0

0.00

2011

7 122

0.03

0.08

100.0

0.0

50.0

33.3

0.28

2012

7 196

0.02

0.06

100.0

0.0

100.0

0.0

0.00

2013

7 274

0.02

0.07

100.0

0.0

60.0

40.0

0.27

2014

7 353

0.02

0.10

100.0

0.0

42.9

14.3

0.14

2015

7 431

0.02

0.03

100.0

0.0

100.0

0.0

0.00

2016

7 244

0.02

0.04

100.0

0.0

100.0

0.0

0.00

2017

7 306

0.01

0.04

100.0

0.0

33.3

0.0

0.00

2018

7 372

0.01

0.07

80.0

0.0

100.0

0.0

0.00

Part II. Country profiles : China, Macao SAR

CHINA, MACAO SAR Population 631 636 (2018)

Background • • • •

Very few cases are still reported. The case finding strategy is passive. Leprosy has been a disease notifiable to the Health Bureau under the law since 1987. The Government is responsible for providing treatment of leprosy.

Elimination target •

Leprosy is not a public health problem.

Epidemiology •

The prevalence rate below the elimination level (1 per 10 000 population) has been maintained for all reporting years, but new cases are still reported sporadically.

Post-elimination activities •

Not applicable.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in China, Macao SAR New case detection rate

1.0 0.8 0.6 0.4 0.2 0.0

New cases per 100 000

Cases registered per 10 000

Prevalence rate

1983

1988

1993

1998

2003

2008

2013

1.0 0.8 0.6 0.4 0.2 0.0

2018

1983

1988

1.0 0.8 0.6 0.4 0.2 0.0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1.5

Number

2.0

1.0

1988

0.0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1993

1998

2003

2008

2013

2018

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child Proportion of child cases

Percentage (%)

New cases per million

2018

1.0

New cases with Grade 2 disability (Rate)

Target

1983

1988

1993

1998

2003

2008

2013

10 8 6 4 2 0

2018

1983

1988

Proportion of cases with Grade 2 disability 120 100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

Percentage (%)

2013

0.5

2008

Number of child cases

2.0

2.5 2.0 1.5 1.0 0.5 0.0

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability

0.0

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

120 100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : China, Macao SAR

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in China, Macao SAR

1991

369

0.49

0.54

1992

378

0.66

0.53

50.0

1993

385

0.34

0.26

398

0.18

0.00

1998

417

0.00

1999

424

0.05

0.47

50.0

0.0

50.0

0.0

0.00

2000

432

0.02

0.23

0.0

0.00

2001

440

0.00

2002

449

0.00

2003

459

0.02

0.22

100.0

0.0

100.0

2.18

2004

470

0.04

0.43

0.0

100.0

0.0

0.00

2005

481

0.00

2006

493

0.00

2007

506

0.00

2008

518

0.02

0.19

100.0

0.0

100.0

0.0

0.00

2009

531

0.00

2010

544

0.00

2011

556

0.00

2012

567

0.00

2013

579

0.02

0.17

100.0

0.0

0.00

2014

590

0.00

2015

601

0.02

0.17

100.0

0.0

100.0

0.0

0.00

2016

613

0.06

0.32

50.0

0.0

0.00

2017

623

0.05

0.00

2018

632

0.02

0.00

1994 1995 1996 1997

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

COOK ISLANDS Population 17 518 (2018)

Background • • • •

There were few new cases from 1988 to 1995. MDT has been used since 1986. Leprosy services are fully integrated with general health services. Case finding is mainly passive and through school surveys.

Elimination target •

Leprosy is not a public health problem.

Epidemiology • •

New cases had been reported sporadically until 1995. Since 1997, no new cases have been reported.

Post-elimination activities •

Not applicable.

Part II. Country profiles : Cook Islands

Leprosy profile in Cook Islands New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate 12 10 8 6 4 2 0

Target

1983

1988

1993

1998

2003

2008

2013

40 30 20 10 0

2018

1983

1988

40 30 20 10 0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

6 5 4 3 2 1 0

Percentage (%)

New cases per million

1998

2003

2008

2013

2018

1983

Percentage (%)

Percentage (%) 1993

1998

2003

2008

2013

1998

2003

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

10 8 6 4 2 0 1988

1993

10 8 6 4 2 0

Proportion of cases with Grade 2 disability

1983

2018

Proportion of child cases

0.10 0.08 0.06 0.04 0.02 0.00 1993

2013

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

1988

2008

Number of child cases

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983

2003

60 50 40 30 20 10 0

Number of cases with Grade 2 disability 6 5 4 3 2 1 0

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Cook Islands

1986

8.46

1987

9.05

1988

34.07

1990

0.00

1991

1.13

11.28

0.0

0.00

1992

0.00

1993

0.00

1994

0.00

1995

0.55

10.93

50.0

0.0

0.00

1997

0.00

1998

0.56

0.00

1999

0.00

2000

0.00

2001

0.00

2002

0.00

2003

0.00

2004

0.00

2005

0.00

2006

0.00

2007

0.00

2008

0.00

2009

0.00

2010

0.00

2011

0.00

2012

0.00

2013

0.00

2014

0.00

2016

0.00

2017

0.00

2018

0.00

1989

1996

2015

Part II. Country profiles : Fiji

FIJI Population 883 483 (2018)

Background • •

• •

Leprosy has been prevalent for many years. Control programmes were integrated within a central unit, including a clinic for leprosy cases at Twomey Memorial Hospital that also served as regional training centre for leprosy for the South Pacific region. MDT has been used since 1983. School surveys are carried out on a regular basis for case finding.

Elimination target •

Reached in 1992 and sustained for more than 20 years.

Epidemiology • • •

Both prevalence and new case detection rates fell sharply in the 1980s. The prevalence rate has been below elimination level since 1992. Between 2004 and 2018, a total of 24 new cases were reported. Of them, 18 (75%) were MB cases.

Post-elimination activities • •

Known pockets of endemicity are being monitored. IEC activities are carried out to sustain leprosy awareness in the community and among health staff.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in Fiji New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate 8 6 4 2

Target

0 1983

1988

1993

1998

2003

2008

2013

7 6 5 4 3 2 1 0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: −0.9 % Proportion of MB cases

6 5 4 3 2 1 0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988

1993

1998 Only MB

Total

2003

2008

2013

120 100 80 60 40 20 0

2018

1983

1988

Number of cases with Grade 2 disability

Number

2018

1983 1988 1993 1998 2003 2008 2013 2018 Adult

Target

1988

1993

1998

2003

2008

2013

60 50 40 30 20 10 0

2018

1983

1988

Proportion of cases with Grade 2 disability Percentage (%) 1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

100 80 60 40 20 0 1983

Child

Proportion of child cases Percentage (%)

New cases per million

2013

10 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983

Percentage (%)

2008

New cases with Grade 2 disability (Rate)

2003

12 10 8 6 4 2 0

1998

Number of child cases

1993

PB + Unknown

2018

60 50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Fiji

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Fiji

1983

685

455

6.64

5.25

47.2

16.7

1984

700

444

6.34

3.57

52.0

8.0

1985

712

367

5.16

3.09

54.5

13.6

1986

719

283

3.94

2.78

20.0

1987

722

243

3.37

2.63

68.4

15.8

1988

723

204

2.82

2.35

70.6

23.5

1989

725

147

2.03

2.21

81.3

1991

735

1.17

0.82

50.0

1992

744

0.66

1.48

54.5

1993

755

0.52

0.93

57.1

1994

766

0.51

1.18

55.6

11.1

77.8

9.14

1995

776

0.31

0.77

33.3

1996

785

0.22

0.76

50.0

0.0

0.00

1997

793

0.16

1.01

100.0

12.5

1.26

1998

801

0.15

0.87

71.4

0.0

0.00

1999

807

0.09

0.87

100.0

0.0

14.3

1.24

2000

812

0.09

1.11

66.7

11.1

2001

815

0.07

0.74

83.3

0.0

0.00

2002

816

0.02

0.49

0.0

25.0

0.0

0.00

2003

817

0.02

0.24

50.0

0.0

0.00

2004

819

0.05

0.37

33.3

0.0

0.00

2005

823

0.06

0.49

75.0

25.0

0.0

0.00

2006

828

0.04

0.48

2007

835

0.11

0.72

2008

844

0.08

0.47

0.0

50.0

0.0

0.00

2009

852

0.02

0.23

100.0

0.0

0.00

2010

861

0.07

0.23

100.0

0.0

0.00

2011

868

0.46

100.0

25.0

2012

876

0.03

0.34

100.0

0.0

33.3

0.0

0.00

2013

883

0.09

0.68

100.0

0.0

33.3

0.0

0.00

2014

890

0.08

0.56

60.0

0.0

40.0

20.0

1.12

2015

896

0.03

0.33

66.7

0.0

33.3

66.7

2.23

2016

872

0.03

0.33

100.0

0.0

33.3

1.10

2017

877

0.04

0.44

75.0

25.0

0.0

75.0

3.29

2018

883

0.10

1.02

77.8

11.1

22.2

2.26

1990

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

FRENCH POLYNESIA Population 277 679 (2018)

Background • • • •

In the 1940s, the disease was highly endemic with prevalence rates of about 24 per 10 000 population. The programme was mainly vertical, with a central leprosy unit. Modified MDT has been used since 1982, with daily rifampicin doses both for PB and MB with a fixed duration regimen. Case finding is mainly passive, while active case finding is systematically performed in contacts of known cases.

Elimination target •

Data on prevalent cases have been available since 1991 when leprosy was already eliminated as a public health problem. This has been sustained for more than 20 years.

Epidemiology • •

The number and rate of new cases detected have declined over the last three decades, with some fluctuations. The prevalence rate has been below elimination level for more than two decades.

Post-elimination activities •

Nothing specific was implemented, except close monitoring of the situation and management of the few new cases.

Part II. Country profiles : French Polynesia

Leprosy profile in French Polynesia New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate 1.0 0.8 0.6 0.4 0.2 0.0 1983

1988

1993

1998

2003

2008

2013

15 10 5 0

2018

1983

1988

15 10 5 0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

25 20 15 10 5 0

New cases per million

Percentage (%) 1993

1998

2003

2008

2013

2018

1983

Percentage (%)

Percentage (%) 1993

1998

2003

2008

2013

1998

2003

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

120 100 80 60 40 20 0 1988

1993

50 40 30 20 10 0

Proportion of cases with Grade 2 disability

1983

2018

Proportion of child cases

Target

1988

2013

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

1983

2008

Number of child cases

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

20 15 10 5 0

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability 25 20 15 10 5 0

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

120 100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in French Polynesia

1983

166

14.49

37.5

12.5

18.11

1984

170

7.04

33.3

16.7

8.3

5.87

1985

175

6.28

0.0

27.3

0.0

0.00

1986

180

7.77

42.9

21.4

7.1

5.55

1987

185

10.27

26.3

42.1

10.5

10.81

1988

190

5.27

60.0

20.0

10.0

5.27

1989

194

1.54

0.0

33.3

5.15

1990

195

4.09

37.5

12.5

25.0

10.24

1991

199

0.45

2.51

60.0

0.0

60.0

15.04

1992

203

0.88

5.90

33.3

8.3

4.91

1993

207

0.87

3.37

42.9

14.3

28.6

9.64

1994

212

0.52

4.25

55.6

22.2

0.0

0.00

1995

216

0.56

2.78

83.3

33.3

0.0

0.00

1996

220

0.64

2.73

100.0

33.3

0.0

0.00

1997

225

0.58

2.23

20.0

0.0

0.00

1998

229

0.48

3.05

85.7

0.0

28.6

8.73

1999

234

0.43

1.28

66.7

0.0

33.3

4.28

2000

238

0.67

2.10

20.0

0.0

0.00

2001

241

0.25

1.66

75.0

0.0

100.0

16.57

2002

245

0.69

4.49

90.9

0.0

0.00

2003

248

0.68

4.43

2004

252

0.68

4.37

2005

255

0.63

3.92

50.0

0.0

0.00

2006

258

0.58

3.10

2008

265

0.23

1.89

40.0

20.0

60.0

20.0

3.78

2009

268

0.37

3.36

77.8

11.1

22.2

0.0

0.00

2010

271

0.66

2.22

50.0

0.0

100.0

0.0

0.00

277

0.51

1.08

0.0

33.3

0.0

33.3

3.61

2016

275

0.28

0.71

0.0

50.0

3.53

2017

276

0.00

2018

278

0.00

2007

2011 2012 2013 2014 2015

Part II. Country profiles : Guam

GUAM Population 165 768 (2018)

Background • • • •

New cases have been continuously reported since 1983. MDT was introduced in 1988. New leprosy cases are found mostly among migrants. There is an increasing proportion of cases from the Federated States of Micronesia. Case finding is mainly passive, but contacts of known cases are screened systematically.

Elimination target •

The elimination target was reached in 1994. However, prevalence rates of more than 1 per 10 000 population have been sporadically reported.

Epidemiology • •

The prevalence rate has fluctuated widely, reverting to the pre-elimination levels in 1997–1998 and again in 2008 and in 2013–2016. The number of new cases has increased in recent years, and the majority of them are MB cases, indicating the presence of infectious cases.

Post-elimination activities • • • •

Contacts of known leprosy cases have been screened systematically. The areas where large migrant populations generally live have been surveyed and monitored. IEC activities have been carried out to sustain leprosy awareness in the community. Health staff have received refresher training.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in Guam

2.0 1.5 1.0 0.5 0.0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

15 10 5 0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: 13.6 % Proportion of MB cases

Percentage (%)

New cases per 100 000

New case detection rate by disease type 15 10 5 0 1983

1988

1993

1998 Only MB

Total

2003

2008

2013

120 100 80 60 40 20 0

2018

1983

1988

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

25 20 15 10 5 0

Adult

New cases per million

Percentage (%) 1988

1993

1998

2003

2008

2013

2018

1983

Percentage (%)

1993

1998

2003

2008

2018

2013

Child

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

40 30 20 10 0 1988

2013

120 100 80 60 40 20 0

Proportion of cases with Grade 2 disability

1983

2008

Proportion of child cases

Target

1983

2003

1983 1988 1993 1998 2003 2008 2013 2018

New cases with Grade 2 disability (Rate) 25 20 15 10 5 0

1998

Number of child cases

Number

Number of cases with Grade 2 disability 25 20 15 10 5 0

1993

PB + Unknown

2018

60 50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Guam

1983

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Guam

111

2.69

33.3

0.0

33.3

8.98

1986

119

3.35

50.0

0.0

0.00

1987

122

2.46

66.7

0.0

0.00

1988

125

3.21

75.0

0.0

0.00

1990

134

1.49

100.0

0.0

0.00

1991

137

1.47

3.66

80.0

0.0

0.00

1992

139

1.65

5.04

71.4

14.3

0.0

0.00

1993

141

1.70

2.83

100.0

25.0

7.08

1994

143

0.70

4.18

83.3

1995

146

0.55

4.12

50.0

1997

149

1.34

4.02

66.7

16.7

0.0

0.00

1998

151

1.79

10.59

93.8

6.3

0.0

0.00

1999

153

0.33

3.27

100.0

20.0

0.0

0.00

2000

155

0.32

3.22

80.0

20.0

2001

158

0.06

0.63

100.0

2003

163

0.06

0.61

2004

166

0.06

0.60

100.0

0.0

0.00

2005

169

0.53

3.56

100.0

16.7

0.0

0.00

2006

171

0.18

1.75

2007

173

0.46

3.46

2008

176

0.91

7.41

92.3

23.1

38.5

7.7

5.70

2009

178

0.56

3.38

83.3

33.3

16.7

0.0

0.00

2010

180

0.78

5.56

100.0

20.0

0.0

0.00

2011

182

0.49

4.39

100.0

0.0

0.00

2012

184

0.60

5.42

100.0

20.0

50.0

10.0

5.42

2013

187

1.13

9.11

94.1

5.9

17.6

23.5

21.44

2014

189

1.59

10.06

94.7

15.8

10.5

10.59

2015

191

1.20

12.04

100.0

21.7

4.3

5.24

2016

163

0.97

9.74

100.0

6.3

50.0

0.0

0.00

2017

164

0.66

8.45

92.9

0.0

28.6

7.1

6.03

2018

166

0.36

4.83

100.0

12.5

0.0

0.00

1984 1985

1989

1996

2002

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

JAPAN Population 127 202 192 (2018)

Background • • • • •

Almost all leprosy patients were in sanatoria in the past. If physicians (mainly dermatologists) detected a case, they referred the person to a sanatorium. MDT was not implemented in the country as a public health measure because most of the patients were treated before the MDT period (dapsone single treatment). Presently, MDT is used for new leprosy patients (both from abroad and domestic). At present there is no active survey, and all cases, both of foreign origin and domestic, are passively detected. School-based surveys were conducted in Okinawa (the southern islands of Japan) from 1967 to 1990.

Elimination target • •

Leprosy has not been a public health problem. Almost all leprosy patients were in the sanatoria under the Leprosy Prevention Law.

Epidemiology • • • •

Both prevalence and new case detection rates have been kept low from the 1980s to date. The number of new cases has decreased over time, although new cases have been still reported (less than 10 cases since 2005). Only a few new Japanese cases are registered. Most are residents of Okinawa, which was the last pocket of leprosy in Japan, while others are imported cases from foreign countries. No child cases have been reported for the last three decades, with the exception of 1 case in 1999.

Post-elimination activities • • •

Nothing specific for case detections. Training on leprosy is held annually, targeting dermatologists. There have been support initiatives for former leprosy patients.

Part II. Country profiles : Japan

Leprosy profile in Japan New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate 1.0 0.8 0.6 0.4 0.2 0.0 1983

1988

1993

1998

2003

2008

2013

1.0 0.8 0.6 0.4 0.2 0.0

2018

1983

1988

1.0 0.8 0.6 0.4 0.2 0.0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

Number

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

Number of child cases

20 10

20 10 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

Proportion of child cases Percentage (%)

New cases per million

0.10 0.08 0.06 0.04 0.02 0.00 1983

1988

1993

1998

2003

2008

2013

10 8 6 4 2 0

2018

1983

1988

Proportion of cases with Grade 2 disability

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases 80

60 50 40 30 20 10 0

Percentage (%)

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

60 40 20 0

1983

1988

1993

1998

2003

2008

2013

2018

1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Detection per 100 000

Prevalence per 10 000

0.03

1985

119 989

0.04

1986

120 551

0.03

1987

121 022

0.01

1988

121 433

0.03

1989

121 831

0.02

1990

122 251

0.01

1991

122 703

0.01

1992

123 178

0.01

1993

123 653

0.01

50.0

0.0

11.1

124 815

0.02

45.8

0.0

25.0

1999

125 532

0.02

63.2

5.3

31.6

21.1

0.03

2000

125 720

0.01

57.1

0.0

50.0

0.0

0.00

2001

125 894

0.01

53.8

0.0

38.5

15.4

0.02

2003

126 184

0.00

0.01

75.0

0.0

12.5

0.01

2004

126 299

0.00

0.01

91.7

0.0

25.0

8.3

0.01

2005

126 393

0.00

83.3

0.0

16.7

0.0

0.00

2006

126 465

0.00

0.01

100.0

0.0

14.3

0.01

2007

126 515

0.00

0.01

83.3

0.0

8.3

0.0

0.00

2008

126 545

0.00

0.01

71.4

0.0

57.1

28.6

0.02

2009

126 552

0.00

50.0

0.0

50.0

0.01

2010

126 536

0.00

75.0

0.0

25.0

0.01

2011

126 497

0.00

80.0

0.0

40.0

0.0

0.00

2012

126 435

0.00

33.3

0.0

0.00

2013

126 345

0.00

66.7

0.0

33.3

0.0

0.00

2014

126 225

0.00

60.0

0.0

60.0

40.0

0.02

2015

126 072

0.00

0.01

85.7

0.0

28.6

14.3

0.01

2016

127 763

0.00

33.3

0.0

0.00

2017

127 503

0.00

50.0

0.0

50.0

0.0

0.00

2018

127 202

0.00

100.0

0.0

50.0

0.0

0.00

Disability %

Female %

Child %

119 319

MB %

1984

New cases

Year

Population (000)

Registered cases

Leprosy indicators in Japan

1994 1995 1996 1997 1998

2002

Part II. Country profiles : Kiribati

KIRIBATI Population 115 847 (2018)

Background •

• • •

Leprosy was endemic for many years in Kiribati. However, it has been confirmed that only few islands have been considered as endemic islands such as Abemama, Kuria, Marakei, Onotoa South Tarawa and Tamana. MDT was launched in 1988. The leprosy programme was vertical before 2006, when it was first implemented into other public health programmes. Besides screening of selected groups since 1995, the entire healthy population was given preventive therapy in the form of a single dose of rifampicin, ofloxacin and minocycline (ROM) in Tarawa and in some known endemic islands in 1996–1997.

Elimination target •

The elimination target of a prevalence rate below 1 per 10 000 population was met only in 2000, 2003 and 2011, and it has not been sustained.

Epidemiology •

•

Both prevalence and new case detection rates have fluctuated with sharp increases in 1996– 1997, 2008–2010 and 2018, reflecting the intensified case detection activities conducted during the time. The number of new cases has increased in recent years due to the strengthened programme activities including screening and an awareness campaign, and since 2010 more than 100 cases continue to be detected every year.

Post-elimination activities •

•

Population screening in highly endemic villages in South Tarawa has still continued as a pioneering activity initiated by the Pacific Leprosy Foundation. Some islands will be also visited depending on the availability of funds. Almost all health staff in South Tarawa have been given refresher training while some other outer island staff were given updated training only during outer island tours.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in Kiribati New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate 25 20 15 10 5 0

Target

1983

1988

1993

1998

2003

2008

2013

250 200 150 100 50 0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: 12.4 % Proportion of MB cases

200 150 100 50 0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988 1993 1998 Only MB Total

80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

200 150 100 50 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

200 150 100 50 0

2013

2018

Proportion of child cases Percentage (%)

New cases per million

2008

150 100 50 0

Target

1983

1988

1993

1998

2003

2008

2013

80 60 40 20 0

2018

1983

1988

Proportion of cases with Grade 2 disability Percentage (%)

10 5 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

15 Percentage (%)

2003

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

1998

Number of child cases

Number

Number of cases with Grade 2 disability

1993

2018

70 60 50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Kiribati

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Kiribati

1988

40.52

39.3

1989

88.90

41.3

28.6

1990

45.94

48.5

12.1

1991

80.65

20.3

37.3

1992

59.25

22.7

27.3

1993

54.51

39.0

26.8

1994

6.04

22.32

64.7

29.4

11.8

26.25

1995

1.68

20.71

25.0

37.5

1996

5.36

99.46

21.8

32.1

0.0

0.00

1997

9.79

128

160.59

13.3

32.0

1998

1.60

32.07

26.9

61.5

0.0

0.00

1999

2.54

44.84

21.6

73.0

0.0

0.00

2000

0.95

22.62

36.8

26.3

5.3

11.90

2001

1.05

21.04

55.6

27.8

0.0

0.00

2002

2.30

28.69

68.0

40.0

4.0

11.48

2003

0.90

23.66

38.1

0.0

0.00

2004

3.21

70.80

25.0

45.3

37.5

0.0

0.00

2005

2.07

36.96

32.4

52.9

0.0

0.00

2006

2.78

43.84

43.9

48.8

0.0

0.00

2007

2.84

66.29

49.2

38.1

34.9

0.0

0.00

2008

9.12

43.51

66.7

42.9

0.0

0.00

2009

112

11.43

98.96

48.5

35.1

53.6

2.1

20.40

2010

100

2.01

182

182.84

36.3

24.7

45.1

1.1

20.09

2011

101

0.99

111

109.81

36.9

26.1

43.2

0.0

0.00

2012

103

1.56

114

111.05

32.5

20.2

44.7

0.9

9.74

2013

104

2.30

137

131.42

24.1

29.2

52.6

5.1

67.15

2014

106

7.94

123

116.20

34.1

46.3

1.6

18.89

2015

107

103

9.58

180

167.48

27.8

26.7

54.4

6.7

111.65

2016

113

115

9.88

218

187.29

26.6

36.2

51.4

4.6

85.91

2017

114

110

9.29

187

157.92

40.6

24.1

46.5

4.3

67.56

2018

116

215

18.56

173

149.33

41.0

27.8

51.5

2.9

43.16

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

LAO PEOPLE’S DEMOCRATIC REPUBLIC Population 7 061 507 (2018)

Background • • • • • •

Leprosy was endemic for many decades. MDT has been administered since 1984. The leprosy programme is vertical at the central and provincial levels and integrated at the district and lower levels; it is supervised by the National Dermatology Centre. Case finding is mainly passive. Active case finding is limited to areas with a known high number of cases. Leprosy elimination campaigns (LECs) were conducted in 1997–1998 in selected provinces. The Netherlands Leprosy Relief Association and the Leprosy Mission International support the programme to a considerable extent.

Elimination target • •

Reached in 1998 and sustained since. Subnational elimination was achieved in most provinces, and two provinces out of 18 still have a prevalence rate of more than 1 per 10 000 population.

Epidemiology •

• • •

The prevalence has declined continuously since the 1980s and after elimination, apart from a sharp rise in 1990 when all patients treated with monotherapy (dapsone) started MDT treatment. The rate has been kept below elimination level since 1998. The number and rate of new cases detected have steadily decreased over the years. The rate of new cases with Grade 2 disability has gradually decreased for the last two decades; however, it has not yet fallen below 1 per 1 000 000 population. The proportion of MB among new cases has risen over the years.

Post-elimination activities • • •

Special projects are being undertaken to detect cases in areas and populations that are difficult to access. A pilot post-elimination surveillance system is being developed in a few selected provinces. Besides strengthening of monitoring and supervision, efforts are being made to intensify IEC activities to increase leprosy awareness in the community.

Part II. Country profiles : Lao People’s Democratic Republic

Leprosy profile in the Lao People’s Democratic Republic 12 10 8 6 4 2 0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

20 15 10 5 0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: −7.9 % Proportion of MB cases

Percentage (%)

New cases per 100 000

New case detection rate by disease type 15 10 5 0 1983

1988 1993 1998 Only MB Total

100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

Number 1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

700 600 500 400 300 200 100 0

Percentage (%)

New cases per million

2018

10 5 0

1988

1993

1998

2003

2008

2013

2018

1983

1988

50 40 30 20 10 0 1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

Percentage (%)

2013

Proportion of cases with Grade 2 disability

1983

2008

Proportion of child cases

Target

1983

2003

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate) 30 25 20 15 10 5 0

1998

Number of child cases

Number of cases with Grade 2 disability 700 600 500 400 300 200 100 0

1993

2018

60 50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in the Lao People’s Democratic Republic

1985

3 680

3 152

8.56

307

8.34

33.9

1986

3 785

3 381

8.93

426

11.25

64.1

1987

3 895

2 353

6.04

702

18.02

30.1

1988

4 009

1 955

4.88

168

4.19

45.8

1989

4 127

1 376

3.33

264

6.40

40.9

1990

4 192

2 529

6.03

371

8.85

43.1

1991

4 312

1 393

3.23

340

7.88

47.1

1992

4 435

1 361

3.07

317

7.15

47.0

34.1

24.35

1993

4 557

1 085

2.38

234

5.13

41.9

38.0

19.53

1994

4 678

967

2.07

304

6.50

75.0

28.9

18.81

1995

4 795

694

1.45

298

6.21

67.1

3.4

25.2

15.64

1996

4 908

574

1.17

270

5.50

67.8

4.1

29.3

16.10

1997

5 017

533

1.06

256

5.10

66.0

3.5

26.2

13.36

1998

5 121

373

0.73

236

4.61

66.1

2.1

19.1

8.79

1999

5 221

282

0.54

177

3.39

74.0

4.0

24.9

8.43

2000

5 317

286

0.54

304

5.72

70.1

6.6

15.8

9.03

2001

5 409

200

0.37

183

3.38

77.0

6.6

15.3

5.18

2002

5 497

162

0.29

155

2.82

76.8

3.9

17.4

4.91

2003

5 582

144

0.26

156

2.79

75.0

7.1

16.0

4.48

2004

5 667

210

0.37

215

3.79

78.6

6.0

45.1

19.5

7.41

2005

5 753

140

0.24

143

2.49

76.2

5.6

35.0

14.0

3.48

2006

5 842

163

0.28

150

2.57

66.0

2.7

26.7

17.3

4.45

2007

5 931

112

0.19

125

2.11

84.0

4.0

30.4

11.2

2.36

2008

6 022

172

0.29

1.54

72.0

4.3

22.6

20.4

3.16

2009

6 112

188

0.31

101

1.65

72.3

2.0

17.8

13.9

2.29

2010

6 201

0.15

1.39

75.6

1.2

23.3

15.1

2.10

2011

6 288

0.15

1.48

82.8

3.2

29.0

16.1

2.39

2012

6 374

0.11

1.38

69.3

4.5

42.0

18.2

2.51

2013

6 459

0.10

1.30

82.1

3.6

41.7

33.3

4.34

2014

6 543

0.14

104

1.59

76.0

12.5

41.3

31.7

5.04

2015

6 628

0.14

1.33

67.0

5.7

43.2

22.7

3.02

2016

6 846

0.08

0.93

78.1

4.7

42.2

28.1

2.62

2017

6 953

0.14

1.29

70.0

6.7

32.2

20.0

2.59

2018

7 062

0.11

1.01

88.7

12.7

21.1

25.4

2.55

Part II. Country profiles : Malaysia

MALAYSIA Population 31 528 033 (2018)

Background • • •

• •

The National Leprosy Control Programme was integrated into the General Public Health Care System in 1995 and is coordinated by the Disease Control Division. MDT was launched in 1985, and the regimen was fully implemented as the first-line treatment in 2012. People can be screened for leprosy at primary health clinics and treated when diagnosis is established after a laboratory test. Any complicated leprosy case or doubtful diagnosis will be referred to a state dermatology clinic. Case detection is mainly passive, but since 2012 active case finding has been increasingly implemented as a Ministry of Health effort towards eradication of the disease. While most patients successfully complete treatment, a few cases, especially among illegal migrants, are lost to follow-up.

Elimination target •

Malaysia achieved the status of leprosy elimination as defined by WHO in 1994.

Epidemiology • • •

•

The prevalence rate declined sharply from 3.8 to 0.9 per 10 000 population between 1987 and 1994. After reaching elimination level in 1994, prevalence gradually fell to below 0.1 per 10 000 population by 2016. The new case detection rate decreased from 2.1 to 0.7 per 100 000 population between 1987 and 1998. Since then, it has been stable within a range of between 0.7 and 1.1 per 100 000 population. The rate of new cases with Grade 2 disabilities sharply decreased in the early 1990s, following the trend of the prevalence rate.

Post-elimination activities •

• •

In October 2014, the second edition of the Guidelines of Leprosy Management was released, followed by the establishment of 44 primary health clinics as treatment centres for leprosy in Peninsular Malaysia to provide easy access to services. Training for health staff has been continuously provided to improve the skills and knowledge in diagnosis and patient management. A mobile health team has conducted a screening programme for high-risk groups in selected districts to facilitate early case detection.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in Malaysia 5 4 3 2 1 0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

2.5 2.0 1.5 1.0 0.5 0.0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: −1.2 % Proportion of MB cases

2.5 2.0 1.5 1.0 0.5 0.0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988 1993 1998 Only MB Total

100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

Number 1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

350 300 250 200 150 100 50 0

Percentage (%)

New cases per million

2013

2018

Proportion of child cases

Target

10 5 0

1988

1993

1998

2003

2008

2013

2018

1983

1988

Percentage (%)

30 20 10 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

Proportion of cases with Grade 2 disability Percentage (%)

2008

1983

2003

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate) 7 6 5 4 3 2 1 0

1998

Number of child cases

Number of cases with Grade 2 disability 350 300 250 200 150 100 50 0

1993

2018

40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Malaysia

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Malaysia

1987

16 704

6 373

3.82

348

2.08

8.0

1988

17 202

5 723

3.33

311

1.81

9.0

19.9

3.60

1989

17 707

5 031

2.84

329

1.86

9.1

28.0

5.20

1990

18 209

4 149

2.28

296

1.63

11.1

23.0

3.73

1991

18 708

3 439

1.84

315

1.68

5.1

19.0

3.21

1992

19 204

2 989

1.56

220

1.15

55.0

19.1

2.19

1993

19 701

3 439

1.75

315

1.60

1994

20 205

1 823

0.90

330

1.63

73.9

7.0

9.1

1.48

1995

20 721

1 561

0.75

293

1.41

73.0

4.8

5.5

0.77

1996

21 247

1 314

0.62

273

1.28

69.6

9.9

3.3

0.42

1997

21 781

1 073

0.49

277

1.27

67.9

5.4

3.2

0.41

1998

22 322

1 125

0.50

148

0.66

52.0

4.1

16.2

1.08

1999

22 868

1 022

0.45

224

0.98

73.2

7.6

4.0

0.39

2000

23 415

631

0.27

207

0.88

62.3

10.6

5.3

0.47

2001

23 965

931

0.39

195

0.81

76.9

4.1

5.1

0.42

2002

24 515

955

0.39

168

0.69

73.2

11.9

1.8

0.12

2003

25 060

972

0.39

219

0.87

52.5

11.9

4.6

0.40

2004

25 590

810

0.32

244

0.95

54.5

7.0

30.7

2.0

0.20

2005

26 100

759

0.29

263

1.01

67.3

6.1

31.2

3.0

0.31

2006

26 586

725

0.27

237

0.89

72.2

7.6

28.3

5.1

0.45

2007

27 051

681

0.25

190

0.70

70.5

5.3

31.1

1.1

0.07

2008

27 502

696

0.25

218

0.79

74.3

2.8

33.5

4.1

0.33

2009

27 949

690

0.25

187

0.67

73.8

6.4

28.9

4.3

0.29

2010

28 401

566

0.20

194

0.68

87.6

7.7

30.9

4.1

0.28

2011

28 859

219

0.08

216

0.75

80.1

6.9

28.2

3.7

0.28

2012

29 322

496

0.17

325

1.11

62.2

7.7

33.8

2.8

0.31

2013

29 787

353

0.12

307

1.03

74.6

8.5

28.3

2.6

0.27

2014

30 252

360

0.12

308

1.02

71.4

7.1

27.9

1.6

0.17

2015

30 714

341

0.11

210

0.68

73.8

5.2

35.7

3.8

0.26

2016

30 685

221

0.07

206

0.65

70.4

2.9

25.2

3.4

0.22

2017

31 105

279

0.09

196

0.61

71.4

9.2

30.6

3.6

0.22

2018

31 528

288

0.09

182

0.58

72.0

5.5

23.6

5.5

0.32

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

MARSHALL ISLANDS Population 58 413 (2018)

Background • • • •

Leprosy has been endemic for many years. The leprosy programme is integrated with the TB control programme. MDT was launched in 1986. In 1998–2002, screening was undertaken, and a number of new cases were detected. A singledose prophylactic treatment with ROM was administered to the family contacts of all known cases.

Elimination target •

Not yet reached.

•

The prevalence rate increased in 1995–1998, and then it declined until 2002. After several years of stagnation, the rate again rose sharply in 2009 and 2011. It has never fallen below the elimination level. The increases in the new case detection rate corresponded to intensified case detection activities conducted in 1996 and 1998–2000. The percentage of children among new cases remains high, with 25–45% in recent years. New cases with Grade 2 disability have been reported sporadically.

Epidemiology

• • •

Post-elimination activities •

Not applicable

Part II. Country profiles : Marshall Islands

Leprosy profile in the Marshall Islands

50 40 30 20 10 0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

300 250 200 150 100 50 0

2018

1983

1988

Proportion of MB cases

300 250 200 150 100 50 0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988 1993 1998 Only MB Total

100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

Number 1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

140 120 100 80 60 40 20 0

Percentage (%)

New cases per million

40 20 Target

1988

1993

1998

2003

2008

2013

2018

1983

Percentage (%)

Percentage (%) 1993

1998

2003

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

25 20 15 10 5 0 1988

2008

60 50 40 30 20 10 0

Proportion of cases with Grade 2 disability

1983

2003

Proportion of child cases

1983

1998

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

1993

Number of child cases

Number of cases with Grade 2 disability 140 120 100 80 60 40 20 0

1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: 0.3 %

2018

60 50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in the Marshall Islands

1983

5.73

1984

13.67

20.0

27.35

1985

18.26

1986

32.33

1987

23.73

1988

43.12

1989

52.39

1990

54.99

1991

10.32

66.03

1992

42.54

1993

4.00

39.97

65.0

0.0

0.00

1994

1.58

15.82

62.5

12.5

0.0

0.00

1995

9.02

35.29

77.8

50.0

1996

16.54

112

217.98

38.4

32.1

0.0

0.00

1997

116

22.44

135.42

41.4

35.7

0.0

0.00

1998

130

25.04

126

242.66

38.1

30.2

2.4

57.78

1999

17.48

116

222.77

19.0

37.1

0.0

0.00

2000

12.28

186.04

32.0

33.0

1.0

19.18

2001

9.98

120.87

46.0

30.2

0.0

0.00

2002

9.22

99.89

63.5

28.8

0.0

0.00

2003

9.62

146.20

48.7

26.3

0.0

0.00

2004

10.59

119.32

59.7

19.4

41.9

0.0

0.00

2005

7.11

84.57

50.0

25.0

0.0

0.00

2006

10.34

80.46

2007

12.00

144.82

56.6

18.4

47.4

2008

10.78

102.13

55.6

20.4

37.0

0.0

0.00

2009

130

24.35

82.41

61.4

25.0

36.4

0.0

0.00

2010

103

19.06

110

203.58

39.1

44.5

13.6

0.9

18.51

2011

226

41.23

120

218.94

50.0

39.2

30.8

0.0

0.00

2012

140

25.13

137

245.93

43.1

38.7

25.5

0.0

0.00

2013

12.88

164.08

59.1

31.2

22.6

0.0

0.00

2014

15.79

140.51

46.9

28.4

34.6

0.0

0.00

2015

9.39

95.63

58.9

41.1

30.4

0.0

0.00

2016

12.05

150.58

71.3

18.8

46.3

0.0

0.00

2017

11.47

99.69

60.4

43.4

34.0

0.0

0.00

2018

10.96

101.00

54.2

30.5

44.1

0.0

0.00

Part II. Country profiles : Micronesia (Federated States of)

MICRONESIA (FEDERATED STATES OF) Population 112 640 (2018)

Background • • • •

Leprosy is highly endemic but unevenly distributed among the states (islands). For example, few cases were reported from Kosrae and Yap states. The leprosy programme is integrated with the TB control programme and has a national programme manager and a coordinator in each state. Rifampicin was introduced in the treatment regimen in 1980, and MDT began in 1984. A special project was carried out in 1996 and 1997 to address the problem of continuing high endemicity. The project consisted of total population screening for detection of leprosy cases and mass preventive therapy with a single dose of ROM to healthy patients. Coverage with prophylactic treatment was up to 87%, with the population screened each year for two years. Screening of people in high-endemic pockets, the family contacts of cases and schoolchildren is being continued with intensified IEC activities.

Elimination target •

Not yet reached. The prevalence rate has stayed above 10 per 10 000 population in recent years.

Epidemiology •

• •

The prevalence rate declined notably from 94.5 to less than 10 per 10 000 population between 1987 and 1998. Since then, the rate has remained relatively low, but the elimination level has not yet been achieved. The new case detection rate increased in the 2000s and 2010s. Several sharp rises in the new case detection rate were not accompanied by an increase in MB cases, showing that many were detected at the early stage of the disease through intensified case finding activities.

Post-elimination activities •

Not applicable.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in the Federated States of Micronesia

120 100 80 60 40 20 0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

350 300 250 200 150 100 50 0

2018

1983

1988

Proportion of MB cases 80

300 250 200 150 100 50 0

Percentage (%)

New cases per 100 000

New case detection rate by disease type 60 40 20 0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

Number 1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

300 250 200 150 100 50 0

New cases per million

Percentage (%) 1988

1993

1998

2003

2008

2013

2018

1983

Percentage (%)

1993

1998

2003

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

10 8 6 4 2 0 1988

2008

60 50 40 30 20 10 0

Proportion of cases with Grade 2 disability

1983

2003

Proportion of child cases

Target

1983

1998

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate) 80 60 40 20 0

1993

Number of child cases

Number of cases with Grade 2 disability 300 250 200 150 100 50 0

1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: 2.5 %

2018

50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Micronesia (Federated States of)

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in the Federated States of Micronesia

1987

851

94.53

177

196.61

1988

782

84.98

94.54

1989

658

69.93

102.03

1990

628

65.20

83.06

1991

501

50.73

85.06

1992

101

349

34.45

88.83

1993

104

362

34.88

220

211.99

1994

106

290

27.40

89.77

42.1

22.1

1995

107

368

34.32

206

192.11

29.6

1996

108

448

41.52

288

266.90

23.3

0.0

0.00

1997

108

169

15.66

123

113.94

28.5

43.9

0.0

0.00

1998

108

6.04

36.24

38.5

43.6

0.0

0.00

1999

107

5.69

61.55

60.6

37.9

3.0

18.65

2000

107

5.32

84.03

52.2

28.9

0.0

0.00

2001

107

5.41

82.02

48.9

50.0

0.0

0.00

2002

108

7.33

108

100.25

52.8

40.7

0.9

9.28

2003

108

6.46

82.16

47.2

41.6

0.0

0.00

2004

109

7.80

153

140.46

41.2

45.1

41.2

0.7

9.18

2005

109

158

14.44

260

237.62

30.0

32.3

36.2

0.8

18.28

2006

110

107

9.75

151

137.54

45.7

25.8

31.1

0.7

9.11

2007

110

7.90

141

128.07

46.1

27.0

20.6

2008

110

190

17.22

124

112.35

58.1

39.5

43.5

0.0

0.00

2009

111

143

12.92

122

110.23

41.0

29.5

37.7

6.6

72.28

2010

111

137

12.34

117

105.34

53.0

18.8

35.0

3.4

36.02

2011

112

175

15.69

196

175.72

40.3

37.8

43.9

1.0

17.93

2012

112

224

19.98

252

224.80

34.1

41.3

36.9

0.8

17.84

2013

113

188

16.68

195

172.99

41.0

39.5

38.5

0.5

8.87

2014

113

126

11.11

178

156.95

40.4

39.9

36.5

2.2

35.27

2015

114

148

12.96

164

143.66

45.7

12.2

27.4

1.8

26.28

2016

110

139

13.17

169

160.12

43.8

23.7

37.3

0.0

0.00

2017

111

0.00

141

132.73

48.9

37.6

35.5

2.1

28.24

2018

113

121

10.74

127

112.75

54.3

30.7

35.4

2.4

26.63

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

MONGOLIA Population 3 170 216 (2018)

Background •

No cases of leprosy are reported in the country.

Elimination target •

Not a public health problem, therefore no targets or programme in the country.

Epidemiology • •

No new and prevalent cases have been reported for all reporting years. Data are not available before 2002.

Post-elimination activities •

Not applicable.

Part II. Country profiles : Mongolia

Leprosy profile in Mongolia New case detection rate

1.0 0.8 0.6 0.4 0.2 0.0

New cases per 100 000

Cases registered per 10 000

Prevalence rate

1983

1988

1993

1998

2003

2008

2013

1.0 0.8 0.6 0.4 0.2 0.0

2018

1983

1988

1.0 0.8 0.6 0.4 0.2 0.0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1.0

0.5

0.5 Number

Number

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

Number of child cases

0.0

−0.5

0.0

−0.5

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

−1.0

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

Proportion of child cases Percentage (%)

New cases per million

0.10 0.08 0.06 0.04 0.02 0.00 1983

1988

1993

1998

2003

2008

2013

10 8 6 4 2 0

2018

1983

1988

Proportion of cases with Grade 2 disability 10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

Percentage (%)

2003

10 8 6 4 2 0

Number of cases with Grade 2 disability

−1.0

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate

1993

2018

10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Mongolia

2002

2 459

2003

2 485

2 547

2008

2 667

2009

2 712

2010

2 756

2011

2 800

2012

2 844

2013

2 888

2014

2 932

2016

3 056

2017

3 114

2018

3 170

2004 2005 2006 2007

2015

Part II. Country profiles : Nauru

NAURU Population 10 670 (2018)

Background • • • •

Leprosy has been prevalent for decades in Nauru, with the first cases detected in migrants in 1912. The disease became epidemic and affected nearly 30% of the population by 1925. Control takes place at the Community Health Clinic of the Division of Public Health. MDT was launched in 1993. School screenings are performed occasionally.

Elimination target •

The target was reached in 1994, when the number of prevalent cases dropped below 10.

Epidemiology • •

The number of new cases has been less than six every year for the last three decades. In 2018, there were eight new cases after two years of no cases.

Post-elimination activities •

Besides monitoring and treatment of the few cases, leprosy awareness among health staff is being maintained through on-the-job training.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in Nauru New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate 15 10 5 0

Target

1983

1988

1993

1998

2003

2008

2013

100 80 60 40 20 0

2018

1983

1988

80 60 40 20 0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

Number

4 2

1988

New cases per million

Percentage (%) 1998

2003

2008

2013

1983

1998

2003

2008

2013

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

Percentage (%)

1993

2003

120 100 80 60 40 20 0

2018

40 30 20 10 0 1988

1998

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

Proportion of cases with Grade 2 disability

1983

1993

Proportion of child cases

Target

1993

2018

New cases with Grade 2 disability (Rate)

1988

2013

4 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983

2008

Number of child cases

120 100 80 60 40 20 0

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

60 50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Nauru

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Nauru

1983

12.73

0.0

1984

12.49

100.0

1985

36.71

33.3

1986

0.00

1987

35.09

0.0

1988

34.28

66.7

0.0

1989

22.33

100.0

50.0

1990

10.93

100.0

1991

21.40

100.0

0.0

0.00

1992

14.68

20.97

100.0

0.0

1993

30.89

66.7

0.0

1994

8.12

20.29

100.0

0.0

0.00

1996

3.99

19.95

100.0

1997

4.98

19.90

100.0

50.0

1999

8.96

29.88

100.0

0.0

2000

6.98

49.83

40.0

0.0

0.00

2001

2.99

29.88

66.7

33.3

99.61

2002

4.98

29.85

66.7

33.3

0.0

0.00

2003

4.97

29.80

2004

4.96

29.73

2005

0.00

9.89

100.0

0.0

0.00

2006

4.94

9.88

2007

2.96

29.57

2008

2.95

19.66

50.0

100.0

0.0

0.00

2009

2.94

29.40

0.0

33.3

0.0

0.00

2010

3.90

19.52

100.0

0.0

0.00

2011

58.25

100.0

2012

7.72

28.95

66.7

0.0

33.3

0.0

0.00

2013

1.92

19.18

100.0

0.0

50.0

0.0

0.00

2014

0.00

2015

1.89

18.94

50.0

0.0

50.0

0.0

0.00

2016

0.00

2017

0.00

2018

7.50

74.98

87.5

0.0

0.00

1995

1998

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

NEW CALEDONIA Population 279 993 (2018)

Background • • •

The programme is run from the dermatology service of the central hospital in Nouméa (Centre Hospitalier Territorial). Modified MDT with a fixed duration was launched in 1983. Rifampicin is given on a daily basis to all cases. Case finding is mainly passive.

Elimination target •

Reached in 1995 and maintained.

Epidemiology • • • •

The prevalence rate decreased in the 1980s and early 1990s, with a sharp drop in 1989. Since 1995, the rate has been below the elimination level. The new case detection rate has also declined over time especially in the 1980s and 1990s, but the rate has appeared to stabilize in the 2000s. The number of new cases detected has ranged from two to 10 every year for the last two decades. New cases with Grade 2 disability have not been reported since 2002.

Post-elimination activities •

Nothing specific, except monitoring of the situation and management of cases.

Part II. Country profiles : New Caledonia

Leprosy profile in New Caledonia

30 25 20 15 10 5 0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

25 20 15 10 5 0

2018

1983

1988

Proportion of MB cases

25 20 15 10 5 0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988 1993 1998 Only MB Total

120 100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

Number 1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

35 30 25 20 15 10 5 0

Percentage (%)

New cases per million

15 10 Target

1983

1988

1993

1998

2003

2008

2013

2008

2013

2018

80 60 40 20 0

2018

1983

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

Proportion of cases with Grade 2 disability 80

80 Percentage (%)

Percentage (%)

2003

Proportion of child cases

1998

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

1993

Number of child cases

Number of cases with Grade 2 disability 35 30 25 20 15 10 5 0

1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: 0.4 %

60 40 20 0

1983

1988

1993

1998

2003

2008

2013

2018

1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in New Caledonia

1983

149

363

24.36

15.44

26.1

47.8

1984

151

334

22.06

13.21

35.0

45.0

1985

154

315

20.46

12.99

40.0

25.0

1986

157

326

20.83

20.45

34.4

21.9

1987

159

339

21.30

13.82

40.9

18.2

1988

162

352

21.72

8.64

35.7

21.4

1989

165

4.24

9.08

53.3

26.7

1990

170

5.30

9.43

37.5

6.3

1991

174

2.77

7.49

30.8

23.1

1992

178

3.60

5.63

50.0

10.0

1993

182

1.21

5.50

60.0

20.0

1994

186

1.45

4.83

33.3

0.0

1995

191

0.68

3.67

71.4

14.3

28.6

10.48

1997

199

0.65

4.51

55.6

0.0

33.3

15.04

1998

204

0.83

2.45

60.0

0.0

60.0

14.73

1999

208

0.48

3.37

57.1

14.3

4.81

2000

212

0.42

3.30

57.1

0.0

28.6

9.44

2001

216

0.79

3.24

71.4

14.3

4.63

2002

220

0.32

0.91

50.0

0.0

0.00

2003

223

0.00

1.79

0.0

25.0

0.0

0.00

2004

227

0.00

1.76

2006

235

0.68

2.98

2007

239

0.17

0.84

2009

247

0.41

2.84

57.1

28.6

0.0

0.00

2010

251

0.36

3.19

50.0

37.5

2011

255

0.47

3.92

70.0

10.0

20.0

2012

259

0.39

1.93

40.0

0.0

20.0

2016

274

0.25

1.09

100.0

66.7

33.3

0.0

0.00

2017

277

0.50

2.50

71.4

57.1

42.9

0.0

0.00

2018

280

0.50

2.86

12.5

50.0

62.5

0.0

0.00

1996

2005

2008

2013 2014 2015

Part II. Country profiles : New Zealand

NEW ZEALAND Population 4 743 131 (2018)

Background • • •

Data were not available prior to 1990. Nearly all cases of leprosy in New Zealand have occurred in individuals who have contracted the disease overseas. All cases are passively detected. Cases are managed in close collaboration among dermatologists, infectious disease physicians, public health services, general practitioners and laboratories.

Elimination target •

Leprosy has not been a public health problem.

Epidemiology • • •

Both prevalence and new case detection rates have been kept low for more than two decades. New cases are still being reported, ranging from one to four cases every year. Past data on new cases with Grade 2 disability are not available. For 2017–2018, no Grade 2 disability was diagnosed in six new cases reported. (Detailed epidemiological data between 2004 and 2013 are available in an article published in 2015.29)

Post-elimination activities •

Not applicable.

Richard Yu, Paul Jarrett, David Holland, Jill Sherwood, Catherine Pikholz. (2015) Leprosy in New Zealand: an epidemiological update. The New Zealand Medical Journal, Volume 128, Number 1414. https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2015/vol-128-no-1414-15-may-2015/6531 [accessed on 4 January 2020]

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in New Zealand New case detection rate

1.0 0.8 0.6 0.4 0.2 0.0

New cases per 100 000

Cases registered per 10 000

Prevalence rate

1983

1988

1993

1998

2003

2008

2013

1.0 0.8 0.6 0.4 0.2 0.0

2018

1983

1988

1.0 0.8 0.6 0.4 0.2 0.0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

10 8 6 4 2 0

Percentage (%)

New cases per million

1998

2003

2008

2013

2018

1983

Percentage (%)

1993

1998

2003

2008

2013

1998

2003

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

10 8 6 4 2 0 1988

1993

60 50 40 30 20 10 0

Proportion of cases with Grade 2 disability

1983

2018

Proportion of child cases

0.10 0.08 0.06 0.04 0.02 0.00 1993

2013

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

1988

2008

Number of child cases

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability 10 8 6 4 2 0

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

120 100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : New Zealand

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in New Zealand

1990

3 398

0.01

0.03

100.0

1991

3 446

0.00

0.12

1992

1993

1994

3 623

0.00

0.03

1995

3 675

0.00

0.03

0.0

1996

3 717

0.03

0.27

70.0

40.0

1997

1998

1999

3 817

0.02

0.26

80.0

0.0

20.0

2000

3 858

0.00

0.10

50.0

0.0

25.0

2001

3 907

0.01

0.08

0.0

33.3

2002

3 962

0.00

0.10

50.0

0.0

75.0

2003

4 021

0.00

0.10

50.0

25.0

50.0

2004

4 079

0.00

0.07

100.0

33.3

2005

4 134

0.00

0.05

50.0

0.0

2006

2007

2008

2009

4 323

0.01

0.07

66.7

0.0

66.7

2010

4 368

0.01

0.07

100.0

0.0

33.3

2011

4 415

0.00

0.02

0.0

100.0

2012

4 461

0.00

0.04

50.0

0.0

2013

4 508

0.01

0.16

42.9

28.6

14.3

2014

4 555

0.09

100.0

0.0

2015

4 601

0.07

66.7

33.3

0.0

2016

4 659

0.00

2017

4 702

0.00

0.06

100.0

0.0

66.7

0.0

0.00

2018

4 743

0.01

0.06

100.0

0.0

0.00

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

NIUE Population 1620 (2018)

Background •

No cases of leprosy were reported.

Elimination target •

Not applicable.

Epidemiology •

No cases have been reported.

Post-elimination activities •

Not applicable.

Part II. Country profiles : Niue

Leprosy profile in Niue New case detection rate

1.0 0.8 0.6 0.4 0.2 0.0

New cases per 100 000

Cases registered per 10 000

Prevalence rate

1983

1988

1993

1998

2003

2008

2013

1.0 0.8 0.6 0.4 0.2 0.0

2018

1983

1988

1.0 0.8 0.6 0.4 0.2 0.0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1.0

0.5

0.5 Number

Number

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

Number of child cases

0.0

−0.5

0.0

−0.5

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

−1.0

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child Proportion of child cases

New cases with Grade 2 disability (Rate) Percentage (%)

New cases per million

0.10 0.08 0.06 0.04 0.02 0.00 1983

1988

1993

1998

2003

2008

2013

10 8 6 4 2 0

2018

1983

1988

Percentage (%)

10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

Proportion of cases with Grade 2 disability Percentage (%)

2003

10 8 6 4 2 0

Number of cases with Grade 2 disability

−1.0

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate

1993

2018

10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Niue

2002

2003

2004

2005

2006

2007

2008

2009

2010

2013

2014

2011 2012

2015

2016

2017

2018

Part II. Country profiles : Northern Mariana Islands (Commonwealth of the)

NORTHERN MARIANA ISLANDS (COMMONWEALTH OF THE) Population 56 882 (2018)

Background • • •

The programme is integrated with the TB control programme and supervised at public health clinics. Rifampicin was introduced in the treatment regimen in 1980, and MDT was introduced in 1986. Case finding is mainly passive.

Elimination target •

First reached in 1992, fluctuated widely between 1994 and 2007, and again since 2008.

Epidemiology • •

Although the prevalence and new case detection rates have fluctuated widely due to the small population, lower rates have been observed in recent years. The number of new cases has been less than 10 per year for the last three decades. A few cases were reported since 2013 after six years without new case detection.

Post-elimination activities • •

Areas with large numbers of migrants are being closely monitored. There is continuous education of community doctors and the general public about leprosy in order to facilitate case detection.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in Northern Mariana Islands (Commonwealth of the)

2.5 2.0 1.5 1.0 0.5 0.0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

20 15 10 5 0

2018

1983

1988

20 15 10 5 0 1983

1988

1993 1998 Only MB Total

2003

2008

2013 2018 PB + Unknown MB

1983

Number

1988

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1993

1998

2003

2008

2013

2018

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child Proportion of child cases

Percentage (%)

New cases per million

2018

New cases with Grade 2 disability (Rate)

Target

1983

1988

1993

1998

2003

2008

2013

120 100 80 60 40 20 0

2018

1983

1988

Percentage (%)

120 100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

Proportion of cases with Grade 2 disability Percentage (%)

2013

2008

Number of child cases

100 80 60 40 20 0

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

120 100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Northern Mariana Islands (Commonwealth of the)

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Northern Mariana Islands (Commonwealth of the)

1983

12.34

1984

7.31

0.0

50.0

36.54

1985

9.89

66.7

33.3

32.96

1986

6.03

1987

11.14

75.0

25.0

1988

7.78

1989

2.42

1990

6.82

1991

17.12

1992

0.81

8.09

100.0

25.0

100.0

80.89

1993

5.75

1994

1.64

1.82

0.0

100.0

0.0

0.00

1995

1.22

10.43

66.7

0.0

0.00

1996

1.83

9.97

66.7

16.7

0.0

0.00

1997

0.64

7.97

60.0

0.0

20.0

15.93

1998

0.92

10.75

71.4

14.3

0.0

0.00

1999

1.04

10.44

100.0

0.0

0.00

2000

1.46

4.38

100.0

0.0

0.00

2001

0.87

7.23

100.0

20.0

14.46

2003

1.16

5.79

75.0

0.0

0.00

2004

1.17

5.85

2006

2.12

10.61

2007

1.09

0.00

2008

0.32

0.00

2009

0.33

0.00

2010

0.66

0.00

2011

0.49

0.00

2012

0.00

2013

0.47

3.15

50.0

0.0

0.00

2014

0.31

1.54

100.0

0.0

0.00

2015

0.30

3.01

100.0

0.0

50.0

0.0

0.00

2016

0.36

3.63

100.0

0.0

100.0

0.0

0.00

2017

0.36

3.62

100.0

0.0

50.0

0.0

0.00

2018

0.58

5.77

100.0

0.0

33.3

0.0

0.00

2002

2005

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

PALAU Population 17 907 (2018)

Background •

• •

The programme is managed and coordinated by the Hansen’s Disease Programme of the Communicable Disease Unit under the Bureau of Public Health Services at Palau Ministry of Health. Case finding is mainly passive. MDT launched in 1982 and is still in place.

Elimination target •

Reached in 1995 when the number of prevalent cases fell below 10. This has been sustained for 20 years.

Epidemiology • • • •

The prevalence rate declined in the 1990s. Since 2000, it has been fluctuating between 0.5 and 4.6 per 10 000 population. No more than 10 new cases have been detected per year for the last three decades. Cases with Grade 2 disability have not been reported since 1996. No child case has been reported since 2014.

Post-elimination activities •

The situation and detected cases are closely monitored.

Part II. Country profiles : Palau

Leprosy profile in Palau

12 10 8 6 4 2 0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

70 60 50 40 30 20 10 0

2018

1983

1988

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

8 6 4 2 0

2018

Percentage (%)

60 40 20 Target

1988

1993

1998

2003

2008

2013

1998

2003

2008

2013

2018

Proportion of child cases

1983

1993

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate) New cases per million

2013

Number of child cases

Number

Number of cases with Grade 2 disability

80 60 40 20 0

2018

1983

1988

Proportion of cases with Grade 2 disability

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

20 15 10 5 0

120 100 80 60 40 20 0

Percentage (%)

2008

120 100 80 60 40 20 0

1983

2003

Proportion of MB cases

60 50 40 30 20 10 0

8 6 4 2 0

1998

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

1983

1988

1993

1998

2003

2008

2013

2018

1983

1988

1993

1998

2003

2008

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Palau

1983

53.78

71.4

0.0

0.00

1984

14.96

50.0

0.0

0.00

1985

14.60

100.0

0.0

0.00

1986

7.15

100.0

0.0

0.00

1987

21.07

66.7

33.3

0.0

0.00

1988

20.71

0.0

33.3

0.0

0.00

1989

6.77

0.0

0.00

1990

33.15

100.0

20.0

0.0

0.00

1991

10.35

38.80

50.0

16.7

64.67

1992

12.59

100.0

0.0

0.00

1993

24.48

75.0

0.0

0.00

1994

7.14

35.72

33.3

0.0

0.00

1995

4.64

52.18

33.3

22.2

11.1

57.98

1996

3.96

22.62

25.0

0.0

0.00

1997

1.10

5.52

0.0

0.00

1998

1.62

16.20

66.7

0.0

0.00

3.13

31.31

83.3

0.0

0.00

2002

1.53

20.44

75.0

0.0

0.00

2003

4.57

35.55

42.9

14.3

0.0

0.00

2004

3.03

30.31

33.3

0.0

0.00

2005

1.01

10.05

100.0

0.0

0.00

2006

0.50

29.99

2007

3.48

19.89

2008

2.47

24.73

100.0

0.0

0.00

2009

3.93

19.67

100.0

0.0

50.0

0.0

0.00

2010

2.93

14.66

100.0

0.0

0.00

2011

1.46

14.56

100.0

33.3

2012

2.89

9.64

50.0

0.0

0.00

2013

2.39

14.34

0.0

66.7

33.3

0.0

0.00

2014

1.90

9.48

100.0

0.0

100.0

0.0

0.00

2015

1.41

9.40

100.0

0.0

50.0

0.0

0.00

2016

1.38

9.20

100.0

0.0

50.0

0.0

0.00

2017

0.00

2018

0.56

5.58

100.0

0.0

0.00

1999 2000 2001

Part II. Country profiles : Papua New Guinea

PAPUA NEW GUINEA Population 8 606 323 (2018)

Background • • • • • •

Leprosy has been prevalent for many years in Papua New Guinea. The disease has been in decline since 1977. The programme is integrated, and programme activities are supervised by a national programme manager. MDT was launched in 1987 and eventually covered all provinces by 1994. Fixed duration treatment began in 1995. Case finding is mainly passive. Special projects such as LECs and SAPELs were conducted in areas of high prevalence and among hard-to-reach populations. The Sasakawa Memorial Health Foundation (Japan), the Leprosy Mission International and WHO provided support to the programme.

Elimination target • •

The elimination target was reached at the national level by the end of 2000. At the provincial level, 14 provinces out of 22 had achieved the elimination target by the end of 2000. Additionally, one province reached the target in 2004, while the remaining five provinces are yet to reach the target as of 2014.

Epidemiology • • • •

The prevalence rate decreased from 27.9 to 0.7 per 10 000 population between 1983 and 2000, and has been stable in the range between 0.5 and 1.1 per 10 000 for the last 18 years. The new case detection rate declined in the 1980s and early 1990s. Since 2000 it has been stable at less than 10 per 100 000 population. The proportion of MB cases has increased in recent years. The rate of new cases with Grade 2 disability has been declining over the years with some fluctuations.

Post-elimination activities • • • •

A brainstorming workshop was held in 2001 to formulate post-elimination strategies. Efforts are focused on the five provinces that have not yet reached the elimination target, as well as on the retrieval of patients who were lost to follow-up. IEC activities are being intensified to promote leprosy awareness in the community and among general health staff. In the post-elimination transition period, the leprosy programme has been receiving less funding support and is affected by complacency.

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Prevalence rate

New case detection rate New cases per 100 000

Cases registered per 10 000

Leprosy profile in Papua New Guinea

30 20 10 0

Target

1983

1988

1993

1998

2003

2008

2013

35 30 25 20 15 10 5 0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: −0.7 % Proportion of MB cases

30 25 20 15 10 5 0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988 1993 1998 Only MB Total

100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

Percentage (%)

New cases per million

2013

2018

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

40 30 20 10 0

1988

1993

1998

2003

2008

2013

2018

1983

1988

Percentage (%)

30 25 20 15 10 5 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

Proportion of cases with Grade 2 disability Percentage (%)

2008

Proportion of child cases

Target

1983

2003

Number

1000 800 600 400 200 0

New cases with Grade 2 disability (Rate) 25 20 15 10 5 0

1998

Number of child cases

Number of cases with Grade 2 disability 1000 800 600 400 200 0

1993

2018

50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Papua New Guinea

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Papua New Guinea

1983

3 489

9 752

27.95

912

26.14

1984

3 584

8 715

24.32

683

19.06

1985

3 678

8 203

22.30

773

21.02

1986

3 772

7 543

20.00

568

15.06

1987

3 865

7 465

19.31

579

14.98

1988

3 960

8 163

20.61

650

16.41

1989

4 057

5 188

12.79

544

13.41

1990

4 158

4 330

10.41

512

12.31

1991

4 262

3 799

8.91

519

12.18

1992

4 369

2 297

5.26

304

6.96

1993

4 480

2 353

5.25

514

11.47

1994

4 595

2 196

4.78

413

8.99

41.9

15.0

23.5

21.11

1995

4 716

1 318

2.79

231

4.90

52.4

19.5

20.3

9.97

1996

4 841

1 105

2.28

701

14.48

51.6

20.8

6.0

8.68

1997

4 970

1 004

2.02

547

11.00

56.5

32.5

11.9

13.08

1998

5 104

1 033

2.02

572

11.21

54.0

18.4

7.9

8.82

1999

5 241

504

0.96

713

13.61

44.6

25.5

3.8

5.15

2000

5 379

370

0.69

338

6.28

49.1

26.3

3.8

2.42

2001

5 519

394

0.71

369

6.69

59.6

17.9

6.0

3.99

2002

5 660

628

1.11

552

9.75

43.8

21.2

10.3

10.07

2003

5 803

338

0.58

263

4.53

51.7

22.1

5.3

2.41

2004

5 948

440

0.74

274

4.61

54.4

29.6

10.6

4.88

2005

6 095

538

0.88

381

6.25

53.5

28.6

14.4

9.02

2006

6 245

305

0.49

223

3.57

65.0

27.8

7.2

2.56

2007

6 396

452

0.71

270

4.22

61.9

20.0

37.8

7.4

3.13

2008

6 549

614

0.94

432

6.60

64.1

28.7

36.6

7.4

4.89

2009

6 703

622

0.93

435

6.49

60.7

30.3

40.7

7.8

5.07

2010

6 858

580

0.85

281

4.10

68.0

28.1

33.8

5.0

2.04

2011

7 014

548

0.78

302

4.31

76.8

28.5

33.8

2.0

0.86

2012

7 170

592

0.83

276

3.85

79.7

20.3

33.3

4.0

1.53

2013

7 327

650

0.89

381

5.20

78.2

21.3

33.6

2.4

1.23

2014

7 486

519

0.69

540

7.21

80.7

25.6

35.0

4.4

3.21

2015

7 645

658

0.86

388

5.08

85.6

30.4

43.3

10.8

5.49

2016

8 272

439

0.53

356

4.31

75.6

25.0

39.3

10.4

4.48

2017

8 438

632

0.75

583

6.93

78.4

33.1

37.4

7.7

5.35

2018

8 606

626

0.73

502

5.83

82.1

27.3

39.2

5.2

3.02

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

PHILIPPINES Population 106 651 394 (2018)

Background • • • • • • •

The disease has been present for many decades. Since 1982 there has been a steady decline in prevalence. The leprosy programme is integrated. MDT was launched in 1983 in two provinces (Cebu and Ilocos Norte) and expanded nationwide from 1986 to 1989. Case finding is mainly passive. Special projects such as LECs, mini-LECs and SAPELs have been conducted in high- prevalence provinces and hard-to-reach populations and areas. The American Leprosy Mission, the Sasakawa Memorial Health Foundation (Japan) and the Philippine Leprosy Mission have provided support to the programme.

Elimination target • • •

Reached in 1998 and sustained since. Subnational elimination at regional level was reached by 2001. Fifteen provinces and two cities are yet to achieve elimination as of 2001.

Epidemiology • • •

The prevalence rate considerably decreased in the 1980s and 1990s, and it has been kept below the elimination level since 1998. The new case detection rate increased in the late 1980s. After reaching the peak in 1991, the rate has steadily declined from 11.3 to 2.0 per 100 000 population for the last two decades. The proportion of MB cases has gradually increased over the years. Around 90% of new cases are MB cases in recent years.

Post-elimination activities • • •

100

Efforts are being made to achieve elimination at the subnational level. Intensified IEC activities, as well as on-the-job and refresher training, are being carried out to sustain leprosy awareness in the community and among general health staff. Plans are underway to start a post-elimination surveillance system in selected provinces.

Part II. Country profiles : Philippines

Prevalence rate 8 6 4 2 0

New case detection rate New cases per 100 000

Cases registered per 10 000

Leprosy profile in the Philippines

Target

1983

1988

1993

1998

2003

2008

2013

15 10 5 0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: −4.7 % Proportion of MB cases

Percentage (%)

New cases per 100 000

New case detection rate by disease type 14 12 10 8 6 4 2 0 1983

1988 1993 1998 Only MB Total

120 100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

2013

2018

4000

2000

2000 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child Proportion of child cases

Percentage (%)

New cases with Grade 2 disability (Rate) New cases per million

2008

Number

4000

Target

15 10 5 0

1983

1988

1993

1998

2003

2008

2013

2018

1983

1988

Percentage (%)

10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

Proportion of cases with Grade 2 disability Percentage (%)

2003

6000

Number

6000

4 3 2 1 0

1998

Number of child cases

Number of cases with Grade 2 disability

1993

2018

40 30 20 10 0 1983

1988

1993

1998

2003

2008

101

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

102

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in the Philippines

1983

51 455

37 323

7.25

1 730

3.36

49.0

14.6

1984

52 874

37 377

7.07

1 726

3.26

49.0

14.5

1985

54 324

38 814

7.14

1 139

2.10

49.0

14.3

1986

55 804

38 570

6.91

2 185

3.92

52.0

14.5

1987

57 313

35 281

6.16

2 748

4.79

55.0

14.5

1988

58 844

36 972

6.28

2 442

4.15

63.0

1989

60 391

31 947

5.29

4 163

6.89

65.0

1990

61 629

20 280

3.29

5 725

9.29

1991

63 147

17 347

2.75

7 169

11.35

1992

64 659

15 317

2.37

5 896

9.12

1993

66 174

15 441

2.33

3 442

5.20

1994

67 703

16 486

2.44

4 450

6.57

1995

69 255

11 674

1.69

3 988

5.76

78.8

1996

70 831

8 659

1.22

4 081

5.76

83.7

8.3

0.0

0.00

1997

72 427

8 749

1.21

4 942

6.82

80.6

8.0

5.1

3.48

1998

74 041

7 005

0.95

3 490

4.71

82.4

7.6

5.5

2.59

1999

75 670

4 786

0.63

3 736

4.94

82.8

7.7

4.8

2.37

2000

77 310

4 320

0.56

3 379

4.37

86.6

6.3

7.2

3.14

2001

78 964

3 816

0.48

2 669

3.38

89.2

5.1

2.3

0.77

2002

80 630

3 334

0.41

2 479

3.07

90.5

4.3

1.9

0.58

2003

82 294

3 334

0.41

2 397

2.91

91.0

5.3

3.7

1.07

2004

83 937

3 287

0.39

2 254

2.69

89.8

6.1

4.6

1.23

2005

85 546

3 096

0.36

3 130

3.66

94.3

5.1

1.5

0.55

2006

87 116

3 787

0.43

2 517

2.89

90.5

7.9

2.9

0.85

2007

88 653

2 279

0.26

2 514

2.84

61.3

3.8

20.0

2.7

0.78

2008

90 173

3 338

0.37

2 373

2.63

90.3

4.6

12.0

1.9

0.50

2009

91 703

7 102

0.77

1 880

2.05

93.4

7.6

31.5

5.4

1.10

2010

93 261

2 873

0.31

2 041

2.19

93.9

4.6

20.0

4.2

0.92

2011

94 852

2 701

0.28

1 818

1.92

91.2

7.3

36.6

5.9

1.13

2012

96 471

2 485

0.26

2 150

2.23

91.6

6.9

32.7

4.0

0.89

2013

98 113

2 963

0.30

1 729

1.76

92.7

6.8

30.2

4.2

0.73

2014

99 765

3 655

0.37

1 655

1.66

91.7

7.6

30.7

3.4

0.56

2015

101 421

2 559

0.25

1 617

1.59

92.2

8.1

28.2

3.7

0.59

2016

103 664

4 316

0.41

1 721

1.64

88.3

5.2

34.2

4.0

0.65

2017

105 173

4 126

0.39

1 908

1.79

87.0

6.7

33.3

1.9

0.34

2018

106 651

4 970

0.47

2 176

2.04

89.9

6.8

33.6

2.3

0.48

Part II. Country profiles : Republic of Korea

REPUBLIC OF KOREA Population 51 171 706 (2018)

Background • •

The Korean Leprosy Control Association coordinates the programme. Modified MDT was launched in 1982 (intensive phase with daily rifampicin and continuation until skin smears are negative).

Elimination target •

Leprosy has not been a public health problem.

•

The new case detection rate decreased dramatically in the early 1980s. After several years of stagnation in the late 1980s and early 1990s, it again dropped in 1995. The rate has been lower than 0.1 per 100 000 population since 2005, but five to seven new cases are still being reported every year. The prevalence rate has gradually decreased over the years. Despite the small number of new cases, in relative terms a large number of cases have been registered in recent years. New cases were rarely reported in children.

Epidemiology

• •

Post-elimination activities •

Besides treatment of the few newly detected cases, patients requiring care for disabilities are maintained on a register and followed up in settlement villages.

103

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in the Republic of Korea New case detection rate

1.0 0.8 0.6 0.4 0.2 0.0

New cases per 100 000

Cases registered per 10 000

Prevalence rate

1983

1988

1993

1998

2003

2008

2013

1.0 0.8 0.6 0.4 0.2 0.0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: −12.6 % Proportion of MB cases

1.0 0.8 0.6 0.4 0.2 0.0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988 1993 1998 Only MB Total

120 100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

350 300 250 200 150 100 50 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

350 300 250 200 150 100 50 0

New cases per million

Percentage (%) 1993

1998

2003

2008

2013

2018

1983

Percentage (%)

60 40 20 0

104

1993

1998

2003

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

1988

2013

10 8 6 4 2 0

Proportion of cases with Grade 2 disability

1983

2008

Proportion of child cases

1.0 0.8 0.6 0.4 0.2 0.0 1988

2003

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

1983

1998

Number of child cases

Number

Number of cases with Grade 2 disability

1993

2018

100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Republic of Korea

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in the Republic of Korea

1983

39 295

345

0.88

1984

39 913

293

0.73

1985

40 502

195

0.48

1986

41 059

142

0.35

1987

41 588

131

0.31

1988

42 085

157

0.37

59.2

1.3

22.9

0.86

42 980

1 637

0.38

157

0.37

61.8

1992

43 729

1 469

0.34

136

0.31

75.0

11.8

0.37

1993

44 057

1 309

0.30

130

0.30

63.8

5.4

0.16

1994

44 366

1 209

0.27

113

0.25

62.8

0.9

12.4

0.32

1995

44 662

1 126

0.25

0.09

66.7

0.0

15.4

0.13

1996

44 950

1 072

0.24

0.09

59.0

0.0

5.1

0.04

1997

45 228

707

0.16

0.08

79.4

0.0

50.0

2.9

0.02

1998

45 495

595

0.13

0.09

64.1

0.0

51.3

5.1

0.04

1999

45 749

551

0.12

0.05

61.9

0.0

42.9

23.8

0.11

2000

45 988

535

0.12

0.08

65.7

0.0

45.7

28.6

0.22

2001

46 211

581

0.13

0.08

83.3

0.0

47.2

16.7

0.13

2002

46 421

543

0.12

0.05

90.9

0.0

50.0

31.8

0.15

2003

46 625

518

0.11

0.04

94.1

0.0

52.9

17.6

0.06

2004

46 831

493

0.11

0.04

88.2

0.0

76.5

35.3

0.13

2005

47 044

420

0.09

0.03

100.0

6.7

60.0

26.7

0.09

2006

47 268

388

0.08

0.03

93.3

0.0

40.0

46.7

0.15

2007

47 499

363

0.08

0.03

83.3

0.0

41.7

50.0

0.13

2008

47 734

332

0.07

0.01

85.7

0.0

85.7

42.9

0.06

2009

47 964

312

0.07

0.01

100.0

0.0

80.0

60.0

0.06

2010

48 184

283

0.06

0.01

100.0

0.0

33.3

0.04

2011

48 391

265

0.05

0.01

57.1

0.0

28.6

14.3

0.02

2012

48 588

255

0.05

0.01

60.0

0.0

20.0

0.02

2013

48 775

210

0.04

0.01

85.7

0.0

28.6

42.9

0.06

2014

48 952

199

0.04

0.01

83.3

0.0

33.3

0.04

2015

49 120

190

0.04

0.00

50.0

0.02

2016

50 983

166

0.03

0.01

75.0

0.0

50.0

25.0

0.02

2017

51 096

125

0.02

0.01

100.0

0.0

33.3

0.0

0.00

2018

51 172

129

0.03

0.01

100.0

0.0

16.7

0.02

1989 1990 1991

105

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

SAMOA Population 196 129 (2018)

Background • • •

The leprosy programme is partially integrated and supervised by the TB and leprosy section of the Public Health Division of the Ministry of Health. MDT was launched in 1985. Case finding is mainly passive.

Elimination target •

The elimination target was first reached in 1993 but has fluctuated for several years since then. However, the prevalence rate has been kept below the elimination level since 2000.

Epidemiology • • • •

The prevalence rate decreased in the 1990s and it has been lower than 1 per 10 000 population since 2000. The new case detection rate has been fluctuating in the range between 2.6 and 12.0 per 100 000 population due to the small population. The number and rate of new cases with Grade 2 disability have decreased in recent years compared with the late 1990s and early 2000s. The proportion of MB cases remains high, indicating delays in diagnosis.

Post-elimination activities •

106

Besides closely monitoring the leprosy situation and treating newly detected patients, efforts are being made to sustain leprosy awareness in the community and among health staff through intensified IEC activities and refresher training.

Part II. Country profiles : Samoa

Leprosy profile in Samoa 3.0 2.5 2.0 1.5 1.0 0.5 0.0

New case detection rate New cases per 100 000

Cases registered per 10 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

15 10 5 0

2018

1983

1988

14 12 10 8 6 4 2 0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

Number

10 5

1988

2018

1993

1998

2003

2008

2013

2018

5 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child Proportion of child cases

Percentage (%)

New cases per million

2013

New cases with Grade 2 disability (Rate)

40 20 Target

1983

1988

1993

1998

2003

2008

2013

50 40 30 20 10 0

2018

1983

1988

Percentage (%)

120 100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

Proportion of cases with Grade 2 disability Percentage (%)

2008

Number of child cases

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

107

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

108

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Samoa

1985

160

9.37

53.3

20.0

1986

161

9.96

62.5

6.3

1987

161

11.80

57.9

5.3

1988

161

6.81

27.3

9.1

1989

162

11.11

27.8

16.7

1990

161

2.23

8.06

15.4

38.5

1991

163

2.09

6.15

40.0

20.0

1992

164

1.53

5.49

77.8

0.0

1993

165

0.85

3.03

60.0

0.0

1994

167

1.20

6.00

70.0

0.0

1995

168

1.25

7.73

76.9

15.4

1996

170

1.12

7.65

92.3

7.7

23.1

17.65

1997

172

0.93

7.57

53.8

7.7

0.0

0.00

1998

174

0.92

10.95

57.9

21.1

31.6

34.57

1999

175

1.14

11.99

76.2

9.5

38.1

45.67

2000

177

0.23

2.83

100.0

0.0

100.0

28.32

2001

178

0.96

7.32

76.9

7.7

76.9

56.29

2002

178

0.45

6.72

66.7

8.3

16.7

11.21

2003

179

0.73

6.14

90.9

9.1

72.7

44.66

2004

180

0.45

5.56

50.0

10.0

20.0

11.13

2005

180

0.28

3.88

100.0

28.6

11.10

2006

181

0.22

2.77

2007

181

0.22

2.76

2008

182

0.28

3.30

83.3

33.3

0.0

0.00

2009

182

0.22

2.74

100.0

0.0

20.0

0.0

0.00

2010

183

0.71

6.55

91.7

16.7

25.0

16.39

2011

184

0.65

4.35

87.5

12.5

50.0

0.0

0.00

2012

185

0.65

4.33

100.0

12.5

25.0

2013

186

0.16

6.46

50.0

16.7

50.0

16.7

10.77

2014

187

0.64

4.29

100.0

12.5

5.36

2015

188

0.37

3.20

100.0

33.3

83.3

0.0

0.00

2016

195

0.71

5.60

90.9

0.0

18.2

10.18

2017

195

0.00

2018

196

0.31

2.55

60.0

0.0

0.00

Part II. Country profiles : Singapore

SINGAPORE Population 5 757 499 (2018)

Background •

MDT was launched in 1982.

Elimination target •

Reached in 1997 and sustained since.

Epidemiology • • • •

The prevalence rate largely decreased in the early 1990s. Since 1997, the rate has been kept below the elimination level. The new case detection rate also decreased in the early 1990s. New cases are nonetheless being reported every year, ranging from five to 20 cases per year for more than a decade. No child cases have been reported since 2003, except for one case in 2014. No new cases with Grade 2 disability have been reported since 1995.

Post-elimination activities • •

With effective chemotherapy, leprosy is curable today and patients are now treated in the general health services alongside other diseases. Currently, the Cutaneous Infections Unit of the National Skin Centre undertakes the treatment of leprosy based on WHO therapeutic guidelines.

109

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Prevalence rate 6 5 4 3 2 1 0

New case detection rate New cases per 100 000

Cases registered per 10 000

Leprosy profile in Singapore

Target

1983

1988

1993

1998

2003

2008

2013

5 4 3 2 1 0

2018

1983

1988

1993

1998

2003

2008

2013

2018

Exponential fit: Recent annual change: −8.7 % Proportion of MB cases

Percentage (%)

New cases per 100 000

New case detection rate by disease type

3 2 1 0 1983

1988

Total

1993

1998

Only MB

2003

2008

2013

120 100 80 60 40 20 0

2018

1983

1988

Number

Number 1993

Others

1998

2003

2008

2013

2018

1983

1988

1998

Adult

2013

2018

2003

2008

2013

2018

2013

2018

2013

2018

Child

Proportion of child cases Percentage (%)

New cases per million

1993

With Grade 2 disability

0.8 0.6 0.4 0.2

20 15 10 5 0

0.0 1983

1988

1993

1998

2003

2008

2013

2018

1983

1988

1993

1998

2003

2008

Proportion of female cases

Proportion of cases with Grade 2 disability Percentage (%)

Percentage (%)

2008

120 100 80 60 40 20 0

New cases with Grade 2 disability (Rate)

8 6 4 2 0

80 60 40 20 0

1983

110

2003

Number of child cases

120 100 80 60 40 20 0 1988

1998

PB + Unknown

Number of cases with Grade 2 disability

1983

1993

1988

1993

1998

2003

2008

2013

2018

1983

1988

1993

1998

2003

2008

Part II. Country profiles : Singapore

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Singapore

1990

3 017

1.06

68.8

0.0

34.4

6.3

0.66

1991

3 099

1 406

4.54

0.77

8.3

33.3

1992

3 191

1 171

3.67

119

3.73

16.0

1.7

26.9

1993

3 287

1 063

3.23

0.91

33.3

6.7

16.7

3.3

0.30

1994

3 385

0.65

0.0

45.5

1995

3 482

747

2.15

1.21

38.1

0.0

26.2

0.0

0.00

1996

3 577

0.84

0.0

30.0

1997

3 671

0.12

0.60

18.2

0.0

31.8

0.0

0.00

1998

3 761

0.12

0.32

41.7

0.0

50.0

0.0

0.00

1999

3 845

0.11

0.86

27.3

12.1

39.4

0.0

0.00

2000

3 919

0.08

0.33

15.4

0.0

46.2

0.0

0.00

2001

3 981

0.07

0.35

35.7

0.0

35.7

0.0

0.00

2002

4 032

0.06

0.45

5.6

27.8

0.0

0.00

2003

4 086

0.06

0.49

20.0

0.0

10.0

0.0

0.00

2004

4 160

0.05

0.43

16.7

0.0

44.4

0.0

0.00

2005

4 266

0.06

0.30

0.5

0.0

38.5

0.0

0.00

2006

4 410

0.36

0.0

43.8

2007

4 585

0.15

0.0

14.3

2008

4 772

0.04

0.10

100.0

0.0

20.0

0.0

0.00

2009

4 946

0.02

0.18

22.2

0.0

11.1

0.0

0.00

2010

5 086

0.03

0.26

46.2

0.0

38.5

0.0

0.00

2011

5 188

0.02

0.31

75.0

0.0

43.8

2012

5 256

0.03

0.29

73.3

0.0

26.7

0.0

0.00

2013

5 301

0.02

0.23

66.7

0.0

41.7

0.0

0.00

2014

5 337

0.01

0.11

50.0

16.7

50.0

0.0

0.00

2015

5 375

0.01

0.06

33.3

0.0

66.7

0.0

0.00

2016

5 654

0.01

0.12

42.9

0.0

14.3

0.0

0.00

2017

5 708

0.02

0.10

66.7

0.0

16.7

0.0

0.00

2018

5 757

0.01

0.10

66.7

0.0

33.3

0.0

0.00

111

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

SOLOMON ISLANDS Population 652 857 (2018)

Background •

• •

•

The leprosy programme has been coordinated with the TB programme both at the national and provincial levels. Leprosy services were integrated into general health services in 1982 through the health system strengthening programme. MDT was introduced in 1986. Case detection has been intensified through contact tracing, screening in hotspots and disseminating leprosy information. Active case finding activities were implemented in 2009, 2013 and 2014. Stigma associated with leprosy was common in the past. However, it has been reduced in recent years due to intensified education on leprosy in communities and schools.

Elimination target •

The National Leprosy Control Programme achieved elimination status in 1994. Although the prevalence rate was slightly above the pre-elimination level in 1997, it has been sustained as of 2018.

Epidemiology • •

•

The prevalence rate has been kept below the elimination level since 1998. The new case detection rate has fluctuated widely between 1.1 and 7.2 per 100 000 population since 1998. The fluctuation was the result of intensified active case finding during the high peak years. This implied that a number of cases remain undetected in post-endemic villages, communities and settlements, particularly in Honiara. The proportion of MB among new cases remains continuously high, ranging from 42.9% to 85.7%.

Post-elimination activities •

• • •

112

Efforts are being undertaken to further reduce the disease burden due to leprosy and achieve elimination at the subnational level. Securing sufficient funding for the programme and building health staff capacity will be key to accomplishing these targets. The Pacific Leprosy Foundation and other nongovernmental organizations (NGOs) have offered continuous support to case finding and case management activities. Patients on treatment are subject to review every three months in order to check on their medication, compliance, reactions and clinical improvement. Disabled patients are managed collaboratively by the Leprosy Programme and community-based rehabilitation. Patients with disability are closely monitored from pretreatment to post-treatment periods in order to facilitate early disability management and rehabilitation.

Part II. Country profiles : Solomon Islands

Prevalence rate 2.5 2.0 1.5 1.0 0.5 0.0

New case detection rate New cases per 100 000

Cases registered per 10 000

Leprosy profile in Solomon Islands

Target

1983

1988

1993

1998

2003

2008

2013

20 15 10 5 0

2018

1983

1988 1993 1998 2003 2008 2013 Exponential fit: Recent annual change: 4.0 % Proportion of MB cases

Percentage (%)

New cases per 100 000

New case detection rate by disease type

10 5 0 1983

1988 1993 1998 Only MB Total

100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

Number 1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

50 40 30 20 10 0

Percentage (%)

New cases per million

2003

2008

2013

2018

Proportion of child cases

Target

60 40 20 0

1983

1988

1993

1998

2003

2008

2013

2018

1983

1988

Percentage (%)

30 25 20 15 10 5 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

Proportion of cases with Grade 2 disability Percentage (%)

1998

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate) 10 8 6 4 2 0

1993

Number of child cases

Number of cases with Grade 2 disability 50 40 30 20 10 0

2018

80 60 40 20 0 1983

1988

1993

1998

2003

2008

113

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

114

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Solomon Islands

1983

255

14.93

63.2

28.9

21.1

0.0

0.00

1984

263

10.28

77.8

33.3

51.9

3.7

3.81

1985

271

14.03

73.7

15.8

34.2

5.3

7.39

1986

279

7.53

81.0

19.0

42.9

9.5

7.17

1987

287

8.02

52.2

8.7

52.2

4.3

3.49

1988

295

8.14

54.2

12.5

62.5

4.2

3.39

1989

303

14.51

22.7

11.4

43.2

4.5

6.60

1990

310

6.14

84.2

26.3

57.9

5.3

3.23

1991

318

6.60

81.0

4.8

57.1

9.5

6.28

1992

328

4.58

80.0

6.7

60.0

0.0

0.00

1993

337

1.96

2.37

50.0

0.0

37.5

0.0

0.00

1994

347

1.01

2.60

77.8

0.0

66.7

0.0

0.00

1995

356

0.67

2.81

80.0

10.0

60.0

0.0

0.00

1996

366

0.98

6.82

64.0

28.0

44.0

12.0

8.19

1997

377

1.12

5.58

47.6

33.3

47.6

4.8

2.66

1998

387

0.54

5.43

52.4

14.3

52.4

9.5

5.17

1999

398

0.20

3.02

50.0

41.7

16.7

8.3

2.51

2000

409

0.20

2.94

50.0

41.7

16.7

8.3

2.45

2001

420

0.17

1.67

42.9

0.0

0.00

2002

432

0.60

6.02

57.7

26.9

42.3

0.0

0.00

2003

444

0.11

1.13

60.0

20.0

60.0

0.0

0.00

2004

457

0.11

5.25

20.8

45.8

0.0

0.00

2005

470

0.45

5.32

64.0

36.0

44.0

0.0

0.00

2006

483

0.19

4.14

45.0

0.0

40.0

0.0

0.00

2007

496

0.24

3.02

53.3

13.3

73.3

0.0

0.00

2008

510

0.27

3.33

82.4

17.6

29.4

0.0

0.00

2009

524

0.40

5.72

56.7

46.7

50.0

0.0

0.00

2010

538

0.22

2.60

85.7

21.4

50.0

0.0

0.00

2011

552

0.05

1.63

77.8

11.1

33.3

0.0

0.00

2012

566

0.19

2.29

84.6

46.2

23.1

15.4

3.53

2013

581

0.65

5.17

60.0

56.7

43.3

13.3

6.89

2014

595

0.69

8.06

52.1

25.0

31.3

10.4

8.40

2015

610

0.52

2.13

46.2

30.8

38.5

23.1

4.92

2016

619

0.70

7.03

69.8

16.3

41.9

4.7

3.27

2017

636

0.77

6.58

65.9

22.0

36.6

12.2

8.02

2018

653

0.63

7.20

61.7

21.3

42.6

6.4

4.60

Part II. Country profiles : Tokelau

TOKELAU Population 1319 (2018)

Background • •

The leprosy programme is integrated. MDT was launched in 1990.

Elimination target •

Not a public health problem.

Epidemiology •

One new case was detected in 1991 and another in 1992. No prevalent and new cases have been reported for the last two decades.

Post-elimination activities •

Not applicable.

115

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Prevalence rate

New case detection rate New cases per 100 000

Cases registered per 10 000

Leprosy profile in Tokelau

8 6 4 2

Target

0 1983

1988

1993

1998

2003

2008

2013

80 60 40 20 0

2018

1983

1988

60 40 20 0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

1.0 0.8 0.6 0.4 0.2 0.0

Percentage (%)

New cases per million

1998

2003

2008

2013

2018

1983

Percentage (%)

116

1993

1998

2003

2008

2013

1998

2003

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

10 8 6 4 2 0 1988

1993

10 8 6 4 2 0

Proportion of cases with Grade 2 disability

1983

2018

Proportion of child cases

0.10 0.08 0.06 0.04 0.02 0.00 1993

2013

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

1988

2008

Number of child cases

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983

2003

10 8 6 4 2 0

Number of cases with Grade 2 disability 1.0 0.8 0.6 0.4 0.2 0.0

1998

Proportion of MB cases

80 Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Tokelau

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Tokelau

1990

0.00

1991

63.49

0.0

1992

6.45

64.47

0.0

1994

0.00

1995

0.00

1997

0.00

1998

0.00

1999

0.00

2000

0.00

2001

0.00

2002

0.00

2003

0.00

2004

0.00

2005

0.00

2006

0.00

2008

0.00

2009

0.00

2010

0.00

2011

0.00

2012

0.00

2013

0.00

2016

0.00

2017

0.00

2018

0.00

1993

1996

2007

2014 2015

117

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

TONGA Population 103 197 (2018)

Background • • • •

The programme is integrated into the activities of the General Hospital. The Medical Officer for Communicable Diseases is responsible for the leprosy control programme. Case finding is passive. MDT was launched in 1986.

Elimination target •

Not a public health problem.

Epidemiology • •

A few cases have been sporadically reported. Most recently, three new cases were detected in 2011 and one new case in 2018.

Post-elimination activities •

118

Not applicable.

Part II. Country profiles : Tonga

Prevalence rate

New case detection rate

1.0 0.8 0.6 0.4 0.2 0.0

New cases per 100 000

Cases registered per 10 000

Leprosy profile in Tonga

1983

1988

1993

1998

2003

2008

2013

3 2 1 0

2018

1983

1988

3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

Number 1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

New cases per million

Percentage (%) 1988

1993

1998

2003

2008

2013

3.0 2.5 2.0 1.5 1.0 0.5 0.0

1983

1998

2003

2008

2013

Percentage (%)

1998

2003

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

1993

10 8 6 4 2 0

2018

40 30 20 10 0 1988

2018

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

Proportion of cases with Grade 2 disability

1983

2013

Proportion of child cases

Target

1983

2008

Number of child cases

New cases with Grade 2 disability (Rate) 12 10 8 6 4 2 0

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability 3.0 2.5 2.0 1.5 1.0 0.5 0.0

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

119

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Tonga

1983

0.00

1984

1.07

1985

0.00

1986

2.12

1987

0.00

1988

2.11

1989

1.05

1990

1.05

1991

0.21

1.05

100.0

1992

0.10

0.00

1993

0.10

0.00

0.21

0.00

1997

0.10

1.04

100.0

0.0

0.00

1998

0.21

1.03

100.0

0.0

0.00

1999

0.21

0.00

2000

0.00

2001

0.00

2002

0.00

2003

100

0.00

2004

100

0.00

1.00

0.0

0.00

2005

101

0.00

2006

102

0.00

2007

102

0.00

2008

103

0.00

2009

104

0.00

2010

104

0.00

2011

105

0.29

2.87

100.0

33.3

9.57

2012

105

0.29

0.00

2016

101

0.00

2017

102

0.00

2018

103

0.10

0.97

100.0

0.0

0.00

1994 1995 1996

2013 2014 2015

120

Part II. Country profiles : Tuvalu

TUVALU Population 11 508 (2018)

Background • • •

The leprosy programme is integrated. MDT was started in 1984. Prednisolone may be added to MDT. Active case finding is undertaken occasionally in schools and highly endemic islands. There has been support from the Pacific Leprosy Foundation.

Elimination target •

The elimination target for countries with small populations (less than 10 prevalent cases) has been maintained for more than 20 years.

Epidemiology • • •

A few new cases continue to be reported sporadically, ranging from one to eight cases annually. Previously, the disease was detected only among the family members of a patient, but recently it has been detected among people who have been exposed to it in public. A new case with Grade 2 disability was first detected in 2015 by a visiting team (not detected by local health workers), and treated with MDT and prednisolone.

Post-elimination activities •

Not applicable.

121

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Leprosy profile in Tuvalu

100 80 60 40 20 0

New case detection rate New cases per 100 000

Cases registered per 10 000

10 8 6 4 2 0

New cases per 100 000

Prevalence rate

Target

1983

1988

1993

1998

2003

2008

2013

100 80 60 40 20 0

2018

1983

1988

1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

8 4

2013

2018

1993

1998

2003

2008

2013

2018

4 2 0

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child Proportion of child cases

New cases with Grade 2 disability (Rate) Percentage (%)

New cases per million

0.10 0.08 0.06 0.04 0.02 0.00 1983

1988

1993

1998

2003

2008

2013

120 100 80 60 40 20 0

2018

1983

1988

Percentage (%)

10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

Proportion of cases with Grade 2 disability Percentage (%)

2008

Number of child cases

122

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability

1998

Proportion of MB cases Percentage (%)

New case detection rate by disease type

1993

2018

50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Tuvalu

1990

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Tuvalu

0.00

1992

2.20

0.00

1993

2.19

21.88

1994

3.27

32.67

100.0

0.0

0.00

1995

3.25

0.00

1996

1.08

10.80

100.0

0.0

0.00

2000

0.00

2001

0.00

2002

0.00

2003

0.00

2004

0.00

2005

0.00

2006

0.00

2007

1.03

10.25

2008

1.02

0.00

2009

1.02

0.00

2010

0.00

2011

1.02

10.16

0.0

100.0

0.0

0.00

2012

3.04

30.42

100.0

0.0

0.00

2013

8.10

80.97

100.0

12.5

0.0

0.00

2014

3.03

0.00

2015

5.03

30.19

66.7

0.0

0.00

2016

0.00

62.54

57.1

42.9

28.6

0.0

0.00

2017

2.66

26.58

33.3

0.0

0.00

2018

7.82

69.52

50.0

37.5

0.0

0.00

1991

1997 1998 1999

123

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

VANUATU Population 292 680 (2018)

Background • • •

The leprosy programme is vertical at the national and district levels, and partially integrated at the provincial level. Case finding is mainly passive, with occasional community surveys. MDT was launched in 1982. A modified MDT without dapsone was introduced due to the high level of dapsone intolerance in Vanuatu.

Elimination target •

Reached in 1997 and sustained since.

Epidemiology • •

• • •

The prevalence rate decreased considerably in the late 1990s. The rate has been kept below the elimination level since 1997. The new case detection rate decreased from 25 to 0.6 per 100 000 population with some fluctuations between 1983 and 1998. Since 1999, the rate has been stable at less than 4 per 100 000 population. The number of new cases detected has ranged from one to five for the last decade. New cases with Grade 2 disability have not been reported since 1998. Child cases have been reported sporadically.

Post-elimination activities • •

124

The detected cases are being treated and the situation is closely monitored. Efforts are being made to sustain leprosy awareness in the community and among health staff through health education and orientation training.

Part II. Country profiles : Vanuatu

Prevalence rate 2.0 1.5 1.0 0.5 0.0

New case detection rate New cases per 100 000

Cases registered per 10 000

Leprosy profile in Vanuatu

Target

1983

1988

1993

1998

2003

2008

2013

30 25 20 15 10 5 0

2018

1983

1988

30 25 20 15 10 5 0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

Number 1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

Percentage (%)

New cases per million

6 4 Target

0 1988

1993

1998

2003

2008

2013

30 25 20 15 10 5 0

1983

1998

2003

2008

2013

Percentage (%)

1998

2003

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

1993

120 100 80 60 40 20 0

2018

20 15 10 5 0 1988

2018

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

Proportion of cases with Grade 2 disability

1983

2013

Proportion of child cases

1983

2008

Number of child cases

New cases with Grade 2 disability (Rate)

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability 30 25 20 15 10 5 0

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

100 80 60 40 20 0 1983

1988

1993

1998

2003

2008

125

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

126

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Vanuatu

1983

124

24.95

1984

127

22.03

1985

130

16.15

1986

133

11.27

1987

136

8.08

1988

139

7.89

1989

143

4.90

1990

147

6.82

1991

151

0.99

4.64

28.6

1992

155

1.48

10.95

52.9

5.9

6.44

1993

160

1.81

8.76

14.3

7.1

0.0

0.00

1994

164

0.97

1.83

66.7

33.3

0.0

0.00

1995

168

1.19

8.32

35.7

14.3

7.1

5.94

1996

172

1.16

4.07

28.6

0.0

0.00

1997

175

0.46

3.43

66.7

16.7

5.72

1998

178

0.22

0.56

100.0

0.0

0.00

1999

181

0.11

1.10

50.0

0.0

0.00

2000

185

0.27

1.62

66.7

0.0

0.00

2001

190

0.11

0.53

100.0

0.0

0.00

2002

195

0.41

3.08

83.3

16.7

0.0

0.00

2003

200

0.55

3.50

42.9

28.6

0.0

0.00

2004

206

0.54

1.46

66.7

0.0

0.00

2005

211

0.09

0.00

2006

217

0.00

1.38

2007

222

0.18

1.35

2008

228

0.00

2009

234

0.21

2.14

60.0

40.0

0.0

0.00

2010

240

0.13

1.25

66.7

0.0

0.00

2011

246

0.16

0.81

100.0

2012

252

0.12

1.19

66.7

0.0

2013

258

0.00

2014

264

0.00

1.89

100.0

20.0

0.0

0.00

2015

270

0.04

0.37

100.0

0.0

0.00

2016

278

0.07

0.72

50.0

0.0

50.0

0.0

0.00

2017

286

0.07

0.71

100.0

0.0

50.0

0.0

0.00

2018

293

0.14

1.71

80.0

0.0

80.0

0.0

0.00

Part II. Country profiles : Viet Nam

VIET NAM Population 95 545 962 (2018)

Background • • • • • •

The programme is vertical and the National Institute of Dermatology and Venereology in Hanoi is responsible for the programme at the central level. Activities are integrated into the general health system at the village level. Special projects such as SAPELs and LECs were conducted from 1995 to detect and treat cases in difficult-to-access areas and communities, as well as in highly endemic pockets. The disease is unevenly distributed: 12 provinces in mountainous areas and four provinces on the high plateau have been considered as highly endemic. Case detection is mainly carried out through mass contact tracing and group screening. MDT has been progressively used since 1982.

Elimination target • •

Reached in 1995 and sustained since. Subnational elimination was achieved in all provinces, except one, by the end of 2000.

Epidemiology •

•

• •

The prevalence rate has gone steadily down over the last three decades, with a steep decline observed in the 1980s and early 1990s. The rate has been kept below the elimination level since 1995. Between 1983 and 1997, the new case detection rate fluctuated between 2.8 and 4.4 per 100 000 population. Since 1998, the rate has continuously decreased, reaching 0.1 per 100 000 population in 2018. The proportion of MB among new cases remains high at more than 80% in recent years. The rate of new cases with Grade 2 disability was consistently high in the 1980s and early 1990s, but it fell to below 1 case per million population in 2008.

Post-elimination activities • • •

A five-year plan was developed in 2001 with the aim of further reducing prevalence and case detection rates and rehabilitating disabled leprosy patients with specific annual targets. Action was taken in 2001 to pilot a post-elimination surveillance system in selected provinces based on the protocol developed by WHO Regional Office for the Western Pacific. Efforts are being made to detect and treat all cases in endemic pockets at the sub-provincial level by intensifying IEC activities to sustain leprosy awareness in the community and among general health staff.

127

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Prevalence rate

New case detection rate

New cases per 100 000

Cases registered per 10 000

Leprosy profile in Viet Nam

6 4 2

Target

0 1983

1988

1993

1998

2003

2008

2013

6 5 4 3 2 1 0

2018

1983

1988 1993 1998 2003 2008 2013 2018 Exponential fit: Recent annual change: −16.1 % Proportion of MB cases

5 4 3 2 1 0

Percentage (%)

New cases per 100 000

New case detection rate by disease type

1983

1988 1993 1998 Only MB Total

120 100 80 60 40 20 0

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number of cases with Grade 2 disability

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

Percentage (%)

New cases per million

2013

2018

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

10 5 Target

1988

1993

1998

2003

2008

2013

12 10 8 6 4 2 0

2018

1983

1988

Proportion of cases with Grade 2 disability 50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

2013

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases Percentage (%)

Percentage (%)

2008

Proportion of child cases

1983

128

2003

Number

3500 3000 2500 2000 1500 1000 500 0

New cases with Grade 2 disability (Rate)

1998

Number of child cases

Number

3500 3000 2500 2000 1500 1000 500 0

1993

2018

50 40 30 20 10 0 1983

1988

1993

1998

2003

2008

Part II. Country profiles : Viet Nam

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Viet Nam

1983

58 277

36 616

6.28

2 021

3.47

6.0

41.0

14.23

1984

59 653

34 240

5.74

2 103

3.53

4.0

30.0

10.58

1985

61 049

30 750

5.04

2 062

3.38

7.0

32.0

10.81

1986

62 460

28 240

4.52

2 292

3.67

8.0

30.0

11.02

1987

63 881

26 750

4.19

2 183

3.42

9.0

28.0

9.56

1988

65 314

24 150

3.70

1 847

2.83

8.0

28.0

7.92

1989

66 757

23 463

3.51

2 073

3.11

6.0

28.0

8.69

1990

67 102

20 997

3.13

1 995

2.97

7.0

28.0

8.33

1991

68 536

18 342

2.68

2 500

3.65

24.0

8.75

1992

69 988

9 449

1.35

3 142

4.49

68.0

8.0

22.0

9.87

1993

71 417

7 320

1.02

3 185

4.46

55.0

7.0

18.0

8.02

1994

72 769

7 419

1.02

3 173

4.36

66.0

5.0

20.0

8.73

1995

74 008

5 277

0.71

2 591

3.50

65.2

8.6

35.7

30.1

10.53

1996

75 117

4 527

0.60

2 866

3.82

62.7

7.3

35.5

31.9

12.15

1997

76 111

4 665

0.61

2 807

3.69

64.1

5.7

36.4

30.5

11.23

1998

77 020

3 482

0.45

2 162

2.81

59.1

7.5

37.1

28.9

8.11

1999

77 891

2 077

0.27

1 795

2.30

59.7

6.9

37.7

25.1

5.78

2000

78 758

1 718

0.22

1 477

1.88

61.3

7.1

38.7

20.9

3.92

2001

79 630

1 532

0.19

1 336

1.68

61.5

5.8

37.2

20.0

3.35

2002

80 501

1 269

0.16

1 158

1.44

61.7

5.6

37.7

19.4

2.80

2003

81 377

1 204

0.15

949

1.17

62.2

5.5

35.7

18.9

2.20

2004

82 263

829

0.10

858

1.04

65.3

5.5

37.5

16.9

1.76

2005

83 161

656

0.08

746

0.90

60.6

6.3

36.1

16.2

1.46

2006

84 076

572

0.07

666

0.79

61.7

5.6

36.8

17.3

1.37

2007

85 007

506

0.06

552

0.65

68.3

4.5

32.2

18.5

1.20

2008

85 952

540

0.06

530

0.62

71.3

3.4

38.1

16.2

1.00

2009

86 901

350

0.04

413

0.48

71.4

2.9

27.6

18.9

0.90

2010

87 848

318

0.04

359

0.41

72.1

3.9

27.3

18.7

0.76

2011

88 792

322

0.04

374

0.42

71.9

2.9

32.4

21.4

0.90

2012

89 730

265

0.03

296

0.33

64.5

3.4

35.5

14.9

0.49

2013

90 657

225

0.02

260

0.29

69.2

5.4

31.5

17.3

0.50

2014

91 563

181

0.02

187

0.20

81.8

3.7

35.3

10.7

0.22

2015

92 443

174

0.02

178

0.19

80.3

2.8

29.8

17.4

0.34

2016

93 640

152

0.02

138

0.14

83.3

2.9

28.3

23.9

0.35

2017

94 601

248

0.03

109

0.11

83.5

1.8

34.9

23.9

0.27

2018

95 546

203

0.02

0.10

92.7

0.0

25.0

18.8

0.19

129

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

WALLIS AND FUTUNA Population 11 661 (2018)

Background •

Leprosy was not endemic in the country, although one new case was reported in 2009.

Elimination target •

Not a public health problem.

Epidemiology • •

Data are not available before 2002. One new case was reported in 2009.

Post-elimination activities •

130

Not applicable.

Part II. Country profiles : Wallis and Futuna

Prevalence rate

New case detection rate

1.0 0.8 0.6 0.4 0.2 0.0

New cases per 100 000

Cases registered per 10 000

Leprosy profile in Wallis and Futuna

1983

1988

1993

1998

2003

2008

2013

8 6 4 2 0

2018

1983

1988

8 6 4 2 0 1983

1988 1993 1998 Only MB Total

2003 2008 2013 2018 PB + Unknown MB

1983

1988

Number

1.0 0.8 0.6 0.4 0.2 0.0

New cases per million

Percentage (%) 1998

2003

2008

2013

2018

1983

Percentage (%)

Percentage (%) 1993

1998

2003

2008

2013

1998

2003

2008

2013

2018

1988

1993

1998

2003

2008

2013

2018

2013

2018

Proportion of female cases

10 8 6 4 2 0 1988

1993

10 8 6 4 2 0

Proportion of cases with Grade 2 disability

1983

2018

Proportion of child cases

0.10 0.08 0.06 0.04 0.02 0.00 1993

2013

1983 1988 1993 1998 2003 2008 2013 2018 Adult Child

New cases with Grade 2 disability (Rate)

1988

2008

Number of child cases

1983 1988 1993 1998 2003 2008 2013 2018 Others With Grade 2 disability

1983

2003

120 100 80 60 40 20 0

Number of cases with Grade 2 disability 1.0 0.8 0.6 0.4 0.2 0.0

1998

Proportion of MB cases Percentage (%)

New cases per 100 000

New case detection rate by disease type

1993

2018

10 8 6 4 2 0 1983

1988

1993

1998

2003

2008

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EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Disability per million

Disability %

Female %

Child %

MB %

Detection per 100 000

New cases

Prevalence per 10 000

Registered cases

Year

Population (000)

Leprosy indicators in Wallis and Futuna

2002

0.00

2003

0.00

2004

0.00

2007

0.00

2008

0.00

2009

0.73

7.30

100.0

0.0

0.00

2010

0.00

2016

0.00

2017

0.00

2018

0.00

2005 2006

2011 2012 2013 2014 2015

132

Part III. Web-based Leprosy Dashboard

1. Overview Leprosy surveillance data are reported annually from countries to the WHO Regional Office for the Western Pacific and then to the WHO Global Leprosy Programme, where the information is consolidated for a global leprosy report. Using the accumulated surveillance data, the Regional Office has developed a web-based Leprosy Dashboard that enables tabulation and visualization of all indicators and data presented in this epidemiological report. The Leprosy Dashboard is accessible to all and customizable according to the user’s preference. Figures and data generated by the Leprosy Dashboard can be downloaded. The Leprosy Dashboard can be used for many purposes. For national leprosy elimination programmes, it can be used for assessing epidemiological trends, identifying programmatic gaps and for informed programmatic decision-making. International agencies, partner NGOs, donors and stakeholders may use the Leprosy Dashboard to find surveillance data for report writing and copying graphics for presentations.

2. Description of the Leprosy Dashboard The Leprosy Dashboard has four tabs: Profile, Dashboard, Table and Comparison. The Profile tab generates four graphs showing key indicators of disease burden: 1) prevalence rate; 2) new case detection rate; 3) new case detection rate by disease type; and 4) new case detection rate for cases with Grade 2 disability. A control panel on the left-hand side has a select box, a tick box and several sliders that can be used to change a country selected, adjust year range of the data generated, enable an exponential fitting curve to show annual change, adjust year range of the fitting curve, and adjust the size of graphics. The Dashboard tab generates a set of 10 graphs, including the proportion of MB cases, the number of cases with Grade 2 disability, the number of new cases in children, the proportion of new cases in children, the proportion of cases with Grade 2 disability and the proportion of new cases in females, in addition to the four graphs included in the Profile tab. The control panel enables the same customization as in the Profile tab. The Table tab generates a country data table that includes all key indicators and raw data. The table can be sorted in ascending or descending order using a selected variable, and it can be downloaded as a comma-separated values (CSV) file. The Comparison tab enables a comparison of a user-selected indicator, which can be selected from eight key leprosy indicators, across multiple countries, which can be selected from any countries and areas in the Region. All graphics generated in the Leprosy Dashboard application can be downloaded as PDF files.

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EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

3. How to use the web-based Dashboard Access to the dashboard • •

To open the web-based Leprosy Dashboard, access: https://wpro.shinyapps.io/leprosy_ dashboard/ When accessing the Leprosy Dashboard, the top page (below) will be displayed. The four tabs: Profile, Dashboard, Table and Comparison are shown in a red box. A green box indicates a main panel where graphs are generated. A purple box shows a control panel where users can select a country and adjust other settings.

Fig. 20. Top page of the web-based Leprosy Dashboard

134

Part III. Web-based Leprosy Dashboard

Profile tab •

The Philippines is selected as the default. Any country and area in the Western Pacific Region can be selected from the pull-down menu indicated in a red box. Once the country is selected, graphs will be automatically updated in the main panel.

Fig. 21a. Customization of the Profile tab of the Leprosy Dashboard

•

Using the sliders in the red and green boxes, users can adjust the year range of the graphs and year range of the fitting curve for the new case detection rate. To disable the fitting curve, uncheck the checkbox in the green box of the control panel. Graphics are automatically updated every time users change the settings.

Fig. 21b. Customization of the Profile tab of the Leprosy Dashboard

135

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

•

The size of the graphs, both width and height, can be adjusted by using sliders in the red box. The graphs generated in the main panel can be downloaded in an A4 PDF file by clicking “Download as PDF (A4)” (green box).

Fig. 21c. Customization of the Profile tab of the Leprosy Dashboard

136

Part III. Web-based Leprosy Dashboard

Dashboard tab •

•

By clicking the Dashboard tab, a set of 10 graphs will be automatically displayed. In the same manner as the Profile tab, users can select a country and adjust other settings using the control panel (red box). The customization of the graphs is independent in each tab and not linked to the other tabs. To export all graphs in the main panel as an A4 PDF file, click “Download profile as PDF (A4)”. To export each graph in the main panel in a different page of PDF document, click “Download profile as PDF (slides)”.

Fig. 22. Snapshot of the Dashboard tab of the Leprosy Dashboard

Table tab •

By clicking the Table tab, the country data table will be automatically displayed.

Fig. 23. Snapshot of the Table tab of the Leprosy Dashboard

137

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

•

A country can be selected from the pull-down menu (green box). To sort the data in ascending or descending order by a variable, click the upper or lower arrow beside a variable you want to sort by (red box). The table can be downloaded as a CSV file (purple box).

Fig. 24a. Customization of the Table tab of the Leprosy Dashboard

•

The data may be displayed in multiple pages depending on the length. To see the next page, click “Next” or the next page number at the bottom right of the table (red box).

Fig. 24b. Customization of the Table tab of the Leprosy Dashboard

138

Part III. Web-based Leprosy Dashboard

•

The number of rows displayed in one page can be changed using a pull-down menu at the top of the table (red box).

Fig. 24c. Customization of the Table tab of the Leprosy Dashboard

Comparison tab •

By clicking the Comparison tab, the page below will be displayed as default.

Fig. 25. Snapshot of the Comparison tab of the Leprosy Dashboard

139

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

•

First, choose an indicator for which you want to make a comparison from the list of eight indicators in the sidebar panel (green box). Second, click on a country selection box (red box) and add countries for which you want to make a comparison by typing a country’s name or choosing from the list that will appear when the box is selected. Graphs will be drawn for the selected country in different colours (red box). Up to eight countries can be compared using different colours. To remove the selected countries, click the country’s name and type “Delete” or “Back Space” key.

Fig. 26a. Customization of the Comparison tab of the Leprosy Dashboard

•

Year range and graph size can be adjusted using sliders (red and green boxes, respectively). The graph can be downloaded as a PDF by clicking “Download as PDF(A4)” (purple box) on the top of the control panel.

Fig. 26b. Customization of the Comparison tab of the Leprosy Dashboard

140

Annexes Annex 1. Definitions 1. A case of leprosy A case of leprosy is a person, having one or more of the following, who has yet to complete a full course of treatment: • •

•

hypopigmented or reddish skin lesion(s) with definite loss of sensation; impairment or involvement of the peripheral nerves as demonstrated by: a) definite loss of sensation; or b) weakness of hands/feet or face; or c) autonomic function disorders such as anhidrosis (dry skin) Presence of visible deformities; and signs of the disease with demonstrated presence of bacilli in skin smear or histopathological confirmation.

2. Prevalence and prevalence rate (registered cases) • •

Prevalence: The number of cases registered for treatment at a given point of time. Prevalence rate: The number of cases registered for treatment at given point of time per 10 000 population.

This indicator reflects the magnitude of the problem and helps in planning and evaluating control measures.

3. Detection and detection rate (newly detected cases) • •

Detection: The number of cases newly detected during a given year and never treated before. Detection rate: The number of cases newly detected during a given year per 100 000 population.

This indicator is most appropriate for estimating the true incidence of the disease in a given population when analysed in conjunction with the proportion of patients with Grade 2 disability among newly detected cases.

4. Elimination of leprosy as a public health problem The elimination of leprosy as a public health problem means reducing the prevalence of leprosy to less than 1 case per 10 000 population. For countries with a small population, WHO Regional Office for the Western Pacific Region considers the elimination level to have been reached if the number of prevalent cases is less than 10.

5. Prevalence/detection (P/D) ratio (presented in the web-based dashboard) This is the ratio of prevalence divided by the number of newly detected cases during a given year. It reflects the mean duration of registration of leprosy patients for treatment. Theoretically, if all patients were MB cases and received their 12 monthly doses of MDT within 18 months, the ratio of prevalence to detection would not exceed 1.5. A higher value for this ratio indicates that patients are treated for longer than necessary, do not complete treatment in time or that registers are not updated.

141

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

6. Proportion of children among newly detected cases This is the proportion of newly detected cases aged less than 15 years among the total number of newly detected cases during a given year and expressed as a percentage. This indicator reflects the level of transmission of the disease over the last few years.

7. Proportion of MB patients among newly detected cases This is the proportion of MB patients among the total number of newly detected cases during a given year and expressed as percentage.

8. Proportion of female patients among newly detected cases This is the proportion of female patients among the total number of newly detected cases during a given year and expressed as percentage.

9. Proportion of patients with Grade 2 disability among newly detected cases This is expressed in a given year as a percentage. This indicator reflects the effectiveness of the programme in terms of early case finding and the level of community awareness of the disease.

10. Rate of patients with Grade 2 disability among newly detected cases This is the number of cases with Grade 2 disability at the time of detection/diagnosis during a given year per 1 000 000 population. This indicator reflects the effectiveness of the programme in terms of early case finding and the level of community awareness of the disease. Reduction of new leprosy cases with Grade 2 disability to less than one case per 1 000 000 population is one of the core targets in the Global Leprosy Strategy 2016–2020.

11. Number of patients with Grade 2 disability among newly detected paediatric cases This is given as an absolute number of newly detected cases aged less than 15 years with Grade 2 disability. This indicator reflects the effectiveness of the programme in terms of early case finding and the level of transmission of the disease over the last few years. Zero Grade 2 disability among newly detected paediatric cases is one of the core targets in the Global Leprosy Strategy 2016–2020.

12. Foreign-born leprosy cases This is given as an absolute number of newly detected cases that are foreign born. This indicator allows calculation of the true prevalence of leprosy within the country as well as the prevalence of leprosy among the migrant population.

13. Treatment completion rate, by MB and PB This is calculated in a cohort analysis, in which MB cases registered for treatment two years before and PB cases registered one year before are followed up until completion of the prescribed period of MDT and expressed as percentage. This indicator reflects the effectiveness of the programme in terms of achieving treatment compliance of patients.

14. Number of relapses among all leprosy-notified cases This is given as an absolute number of all cases treated as relapse after treatment with MDT. This indicator reflects the effectiveness of treatment. The important predisposing factors for relapse include the presence of persisting or antimicrobial resistant bacilli, monotherapy and inadequate/irregular therapy.

142

Annexes

Annex 2. Source of the data This leprosy epidemiological report was developed through the compilation of all historical leprosy data in the WHO Western Pacific Region. In the process of developing this present report, the historical leprosy data were reviewed and validated by national leprosy elimination programmes to ensure consistency with the nationally available data. The data presented in this report may therefore contradict with the data presented in previous WHO reports. The following countries and areas of the Region participated in the review and validation of historical data. • • • • • • •

Australia Brunei Darussalam Cambodia Hong Kong SAR (China) Japan Macao SAR (China) Malaysia

• • • • • • •

Mongolia New Zealand Papua New Guinea Singapore Solomon Islands Tuvalu Viet Nam

Population data used for calculating new case detection rates and prevalence rates were sourced from the Population Division of the United Nations Department of Economic and Social Affairs. Programmatic information in the Country Profiles section was sourced from the previous WHO report Overview and epidemiological review of leprosy in the WHO Western Pacific Region, 1991–2001, published in 2003, with some updates reviewed by national leprosy programmes. In addition to the annual statistics on leprosy, the previous report sourced programmatic information from the following: • •

• •

Officially published reports, including the annual World Health Statistics (WHO Geneva), Country Health Information Profiles (WHO Regional Office for the Western Pacific) and national reports. Documents published by the WHO Regional Office for the Western Pacific, including socioeconomic and health indicators. Extensive use was made of the assignment reports to the WHO Regional Office on leprosy provided by most countries for 1983 to 2001. Articles in international medical journals, as available. Unpublished reports: Unpublished data on leprosy collected by WHO, particularly during international meetings, were also used.

143

EPIDEMIOLOGICAL REVIEW OF LEPROSY IN THE WESTERN PACIFIC REGION 1983–2018

Annex 3. List of countries/areas for which leprosy data were not available Year

144

Number of List of countries/areas for which leprosy data were not available countries/areas

1983

1984

1985

1986

1987 1988 1989

7 6 9

1990 1991 1992 1993 1994

5 4 3 5 7

1995 1996

5 10

1997 1998 1999 2000 2001 2002 2003 2004 2005

3 5 4 3 4 2 NA 1 4

2006 2007

5 7

2008 2009 2010 2011 2012 2013 2014 2015

2 NA NA 3 2 3 6 10

2016 2017 2018

NA NA NA

China, Cook Islands, Cambodia, Hong Kong SAR (China),Kiribati, Lao People’s Democratic Republic, Micronesia (Federated States of), Mongolia, Niue, Singapore, Tokelau, Wallis and Futuna, and Samoa American Samoa, China, Cook Islands, Guam, Cambodia, Hong Kong SAR (China), Kiribati, Lao People’s Democratic Republic, Micronesia (Federated States of), Mongolia, Niue, Singapore, Tokelau, Wallis and Futuna, Samoa Cook Islands, Guam, Hong Kong SAR (China), Kiribati, Micronesia (Federated States of), Mongolia, Niue, Singapore, Tokelau, and Wallis and Futuna Hong Kong SAR (China), Kiribati, Micronesia (Federated States of), Mongolia, Niue, Singapore, Tokelau, and Wallis and Futuna Hong Kong SAR (China), Kiribati, Mongolia, Niue, Singapore, Tokelau, and Wallis and Futuna Hong Kong SAR (China), Mongolia, Niue, Singapore, Tokelau, and Wallis and Futuna Cook Islands, Guam, Hong Kong SAR (China), Mongolia, Niue, Republic of Korea, Singapore, Tokelau, and Wallis and Futuna Fiji, Hong Kong SAR (China), Mongolia, Niue, and Wallis and Futuna Mongolia, Niue, Republic of Korea, and Wallis and Futuna Mongolia, Niue, and Wallis and Futuna Hong Kong SAR (China), Mongolia, Niue, Tokelau, and Wallis and Futuna American Samoa, Hong Kong SAR (China), Mongolia, Niue, Singapore, Tonga, and Wallis and Futuna Hong Kong SAR (China), Mongolia, Niue, Nauru, and Wallis and Futuna Cook Islands, Guam, Hong Kong SAR (China), Mongolia, New Caledonia, Niue, Singapore, Tokelau, Tonga, and Wallis and Futuna Mongolia, Niue, and Wallis and Futuna Hong Kong SAR (China), Mongolia, Nauru, Niue, and Wallis and Futuna Mongolia, Niue, Palau, and Wallis and Futuna Mongolia, Niue, and Wallis and Futuna Mongolia, Niue, Palau, and Wallis and Futuna Guam, Northern Mariana Islands (Commonwealth of the) Mongolia American Samoa, New Caledonia, Northern Mariana Islands (Commonwealth of the), and Wallis and Futuna Hong Kong SAR (China), Mongolia, Republic of Korea, Singapore, and Wallis and Futuna American Samoa, French Polynesia, Hong Kong SAR (China), Mongolia, Republic of Korea, Singapore and Tokelau American Samoa and New Caledonia French Polynesia, Niue, and Wallis and Futuna Niue, and Wallis and Futuna French Polynesia, New Caledonia and Tonga French Polynesia, New Caledonia, Niue, Tokelau, Tonga, and Wallis and Futuna American Samoa, Cambodia, Cook Islands, French Polynesia, Mongolia, New Caledonia, Niue, Tokelau, Tonga, and Wallis and Futuna