Prophylaxis--scope and limitations

Attempts to prevent leprosy by one or another prophylactic method began with the use of dapsone as a chemoprophylaxis. Following early, small-scale studies, which were promising, large-scale studies with dapsone and acedapsone, both among contacts and in the general population, demonstrated that it is possible to prevent the occurrence of leprosy to a modest extent. With regard to immunoprophylaxis, BCG had long been considered a possibility, particularly in view of its potential to convert the skin test reaction to lepromin. Over the years, major, large-scale field trials of BCG had been carried out in Uganda, Burma, Papua New Guinea and India. All of the studies demonstrated that BCG was capable of preventing leprosy. However, protective efficacy varied from around 20% to greater than 80%. Killed Mycobacterium leprae mixed with BCG has also given varying results. Other vaccines based on cultivable mycobacteria have also been tried, and at least one of them appears promising. An approach to prophylaxis must take into account (a) the level of risk addressed and the perception of risk by the community; (b) the level of efficacy of the method of prophylaxis; (c) the possibility of easily identifying high-risk groups; (d) the operational feasibility; and (e) the focus of the prophylaxis, whether the individual or the community, or both. However, in view of the enormous progress being made towards elimination of leprosy by the widespread application of MDT, prophylaxis is becoming less and less relevant and less and less cost-effective, except in very special situations.