A/HRC/38/42 Mozambique, Myanmar, Nepal, Nigeria and Philippines. In endemic countries, leprosy mainly affects poorer communities and regions. 11 14. Furthermore, as the prevalence of leprosy declines, new challenges arise, such as the increase of foreign-born cases in countries in which it has already been eliminated. In 2016, 328 foreign-born cases were reported in 23 countries. 12 15. Finally, the number of cases reported globally is not exact, as many cases go unreported due to institutional and extra-institutional barriers in accessing leprosy-related diagnosis and treatment in many parts of the world. A large number of people continue to receive treatment for leprosy and many live with impairments caused by leprosy and with disabilities caused by their social exclusion. In addition, the figure does not cover family members of the affected individuals, who are equally affected by leprosy-related stigmatization and discrimination. 16. Despite the impressive decrease in the number of cases since the introduction of multidrug therapy three decades ago (from over 5 million cases in the mid-1980s to less than 200,000 cases at the end of 2016), no major change in the trends of newly detected cases has been observed. Most recently, an increase in new cases from 210,758 in 2015 to 214,783 in 2016 has been reported.13 This suggests a number of things: 17. First, the prevalence rate may not be reliable in fully assessing the evolution of leprosy, since before the discovery of multidrug therapy, patients had to undergo treatment for years, sometimes for life. Following the introduction of multidrug therapy, treatment time was drastically reduced. Since 2000, such a reduction in treatment has reached 12 months for multibacillary patients and 6 months for paucibacillary patients. Paucibacillary patients may not reach the annual prevalence record, leaving them uncounted. And there are gaps in the reporting of new cases, especially in low-income countries, in which conditions are favourable for higher rates of leprosy and in which well-structured health services are lacking.14 18. Second, the data suggest that more efforts are required to stop the transmission of leprosy. Besides the aforementioned loss of expertise, it is necessary to reframe leprosy under the current debate on the social determinants of health and inclusive development. Leprosy’s transmission depends not only on biological factors, but also on social determinants, including access to sanitation, clean water and education, among others, that have not yet been responded to by public health programmes. 19. Of the 214,783 new cases reported in 2016, 12,437 presented grade-2 disability cases, namely visible impairments. As already mentioned, impairments caused by leprosy are preventable and its incidence means that delays in access to diagnosis and to a highquality treatment have occurred, in sum to the fundamental rights of every human being to the enjoyment of the highest attainable standard of health. In such cases, States have failed to fulfil their obligations to respect, protect and fulfil such a right. 20. Some 281 of the 12,437 new cases reported in 2016 were children with impairments. The overall rate of new cases of leprosy in children represents 8.9 per cent of all new cases, a shamefully high figure. This reveals social vulnerability as a key factor in the transmission and prevalence of leprosy. Additionally, the overall underreporting on women affected by leprosy remains a cause for great concern. 15 This is indicative of the vulnerability of women and their lack of access to health services in many settings, especially in poorer communities. The epidemiology of leprosy is linked to the continuous violation of the human rights of vulnerable groups both within countries and worldwide. 11 12 13 14 15 WHO Regional Office for South-East Asia, Global Leprosy Strategy 2016−2020 — Operational Manual, p. 2. WHO, Weekly Epidemiological Record, No. 35 (92) (2017), pp. 501–520. Ibid. Claudio Guedes Salgado and others, “Are leprosy case numbers reliable?”, Lancet, vol. 18, No. 2 (February 2018), pp. 135–137. WHO, Weekly Epidemiological Record. 5