How a leprosy programme put the WHO’s target of eradicating another NTD on track
Image credit: Tom Bradley
In the Democratic Republic of the Congo (DR Congo), leprosy is a significant problem. Last year, 3,720 new cases of the disease were diagnosed (PNEL epidemiological data 2022), following on from 4,148 cases in 2021(WHO report, 2021). In fact, unlike other countries, DR Congo has seen an increase in leprosy cases through the pandemic thanks to active case finding initiatives.
The national leprosy control programme in DR Congo operates across all 25 Provinces, training health workers to identify and treat the disease.
The system is far from perfect, but it is robust, and it is a lot stronger than any government or NGO intervention against two similar NTDs: Buruli ulcer and yaws, a disease targeted for eradication by WHO.
According to WHO projections, DR Congo also falls within the category of a country that is endemic for both yaws and Buruli ulcer. But statistics show that these diseases are less detected and less supported. Indeed, the results of 2018 show that only 27 cases of yaws, and 99 cases of Buruli ulcer were detected.1
WHO identified yaws eradication as a realistic possibility in DR Congo and made funding available for organisations that could make this a reality. The question remained; how do we make yaws eradication a reality in DR Congo?
The answer is, if yaws is to be eliminated eradicated in DR Congo, it will be through integration into the nation’s already well established leprosy control programme.
1 WHO Global Health Observatory
Finding a way to integrate NTD programmes can be a way to save funds and more efficiently target diseases that are not easy to target on their own. However, that is not true across all NTDs. Some diseases require quite distinct approaches to case management.
In some instances, an approach like mass drug administration is appropriate, whereas other diseases require more precise interventions, such as active case finding.
In this instance, an integrated approach works well because yaws, Buruli ulcer, and leprosy all have similar approaches to case management, they are all skin NTDs, and they are endemic in similar areas of DR Congo.
Having identified the possibility of playing a role in WHO’s target of eradicating yaws in DR Congo, three ILEP partners in DR Congo - The Leprosy Mission, American Leprosy Missions and Damien Foundation - worked together on a pilot project that integrated yaws into their existing leprosy work. The pilot project received funding from The Leprosy Mission Belgium, Solidarité Protéstante, and CHF Foundation USA.
Together they established a plan with the government’s Ministry of Health through the National Leprosy Control Programme. Health workers in three provinces (Haut-Uélé, Maniema, and Kongo Central) who were already trained to identify and care for leprosy cases began to receive training in yaws and Buruli ulcer.
As well as health workers, the teams sought the engagements of communities. Community leaders acted as connectors between key stakeholders, setting up important conversations and helping our teams to raise awareness of the disease. In DR Congo, there is also a position in the health system known as community relay (or Community Health workers in other settings); these individuals were essential in ensuring that communities were also able to identify potential signs of Buruli ulcer and yaws.
The project was run as a study, with control health areas and intervention health areas. Within the intervention health areas, there were data collection tools, awareness tools, and a SkinApp that were implemented.
Health workers were taught to diagnose yaws using DPP (Dual Path Platform) and RPR (rapid plasma regain), two rapid tests for the disease.
Because health workers could now spot yaws and Buruli ulcer, active case finding initiatives for leprosy in the intervention health areas of the study soon began to lead to new cases of yaws and Buruli ulcer being diagnosed.
The pilot achieved above its targets, having demonstrated that more cases of yaws and Buruli ulcer could be found and treated in the intervention health areas when compared to the control health areas.
On paper that sounds like a simple success story, but in a country like DR Congo, that is a significant victory. The country is very large, hugely underfunded, and plagued by insecurity.
The teams faced a number of challenges. The first was that medicine was not arriving from WHO quickly. There were patients that were being diagnosed with yaws and Buruli ulcer but were not receiving any treatment for a long time.
For Buruli ulcer there were significant challenges in diagnosis. The only way to conclusively diagnose the disease is through laboratory testing and the only lab in the country that is capable of this is in Kinshasa. To collect and transport the samples from these provinces to the capital was a logistical challenge.
Lastly, in a country where digital infrastructure lags behind, health staff were unfamiliar with the digital tools they were being asked to use in order to submit data. There were often long delays in receiving the data that was needed to confirm case rates.
Despite these challenges, the teams had one ultimate goal, which was to identify just how cost effectively they could they could run a programme that would increase the rates of diagnosis for all three NTDs: yaws, Buruli ulcer, and leprosy.
Our teams have demonstrated that even in a significantly under-resourced setting, it is possible to economise your efforts by making the most of what is already there.
The national leprosy programme was strong already; when WHO set their target of eradicating yaws in DRC, the decision to share the strength of the leprosy programme has meant that yaws patients have received treatment faster than they could possibly have done through a non-integrated approach. Meanwhile, the leprosy programme has received funding that would not otherwise have been available to it, which has been a benefit to persons affected by leprosy across the country.
There was nothing like this before, no project had thought to bring together all three diseases in one place in our country. Now we have done it and we have seen simply that it works. To find cases of Buruli ulcer or yaws without this approach would have been difficult before, but now it is possible. The eradication of yaws in my country was an achievable goal, but we were not sure how. Now we know how it is possible and we believe we can do it. Most importantly, making space to integrate other NTDs into our programme has benefited patients of all three NTDs.
