[Survey of the quality of leprosy diagnosis in Madagascar]

By 2005, Madagascar had not achieved its goal of eliminating leprosy. During reexamination of leprosy patients, rates of diagnostic error ranged from 4.5 to 62%, casting doubt on the reported prevalence of leprosy. We therefore decided to carry out a survey of the quality of leprosy diagnosis.

The survey consisted in reexamination of a sample of 102 new cases of leprosy (treated for less than three months). The sample was obtained from clusters of six patients, randomly drawn from the 111 districts in the country's six provinces. Two reexamination teams visited the target districts. Each team included at least three medical doctors: a doctor from the National Program, a WHO consultant and a dermatologist from partner NGOs in the program.

The mean false-positive rate was 27.5%, ranging from 5.6 to 44.4% in the different provinces. The quality of leprosy diagnosis was found to be very poor, particularly in districts with a marked decrease in annual detection of leprosy cases.

The high rate of false-positives during this survey could be due to the incompetence of peripheral health workers. This incompetence could be partly attributed to the decrease in leprosy detection, resulting in reduced familiarity of these health staff with leprosy diagnosis. Recommendations were made to the country concerning review of the leprosy case detection network and improvement of the quality of leprosy diagnosis in the field. Health workers involved in leprosy detection must have basic dermatological knowledge.