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1.  Leprosy Elimination: Progress and Challenges in Nigeria; Kaduna State TB and Leprosy Control Programme as a Case Study 
The study aims at describing the achievements and challenges of Leprosy control in Kaduna State using appropriate indicators. The study was a five year (2004–2008) retrospective review of the Leprosy records and annual reports of all the twenty three LGAs in Kaduna State. Various Leprosy indicators were calculated and presented in different graphic presentations. Focus group discussions were organised with the aim of identifying current challenges of Leprosy control in the State. There was a decline in the new Leprosy cases detected annually from 226 cases in 2004 to 140 cases in 2008. The prevalence rate ranged between 0.3–0.4 per 10,000 population within the five year period. The proportion of children among new cases dropped from 12% in 2004 to 5% in 2007 and increased to 9% in 2008. Grade 2 disability among new cases was very high (between 21%–27%) within the same period. Leprosy elimination target has been achieved in Kaduna State, but new cases with high proportion of children and WHO grade 2 disability were still been reported
PMCID: PMC3555439  PMID: 23878709
Leprosy; Elimination; Leprosy indicators
2.  Elimination of Leprosy as a public health problem by 2000 AD: an epidemiological perspective 
Introduction
Leprosy is caused by Mycobacterium leprae and manifests as damage to the skin and peripheral nerves. The disease is dreaded because it causes deformities, blindness and disfigurement. Worldwide, 2 million people are estimated to be disabled by leprosy. Multidrug therapy is highly effective in curing leprosy, but treating the nerve damage is much more difficult. The World Health Assembly targeted to eliminate leprosy as a public health problem from the world by 2000. The objective of the review was to assess the successes of the leprosy elimination strategy, elimination hurdles and the way forward for leprosy eradication.
Methods
A structured search was used to identify publications on the elimination strategy. The keywords used were leprosy, elimination and 2000. To identify potential publications, we included papers on leprosy elimination monitoring, special action projects for the elimination of leprosy, modified leprosy elimination campaigns, and the Global Alliance to eliminate leprosy from the following principal data bases: Cochrane data base of systematic reviews, PubMed, Medline, EMBASE, and the Leprosy data base. We also scanned reference lists for important citations. Key leprosy journals including WHO publications were also reviewed.
Results
The search identified 63 journal publications on leprosy-related terms that included a form of elimination of which 19 comprehensively tackled the keywords including a book on leprosy elimination. In 1991, the 44th World Health Assembly called for the elimination of leprosy as a public health problem in the world by 2000. Elimination was defined as less than one case of leprosy per 10000-population. Elimination has been made possible by a confluence of several orders of opportunities: the scientific (the natural history of leprosy at the present state of knowledge), technological (multi-drug therapy and the blister pack); political (commitment of governments) and financial (support from NGOs for example the Nippon Foundation that supplies free multi-drug therapy) opportunities. Elimination created the unrealistic expectation that the leprosy problem could be solved by 2000. First, the elimination goal was not feasible in several areas which had high incidence of leprosy. Even if elimination was to be attained, significant numbers of new cases of leprosy would continue to occur and many people with physical imperfections, severe psychological, economic and social problems caused by leprosy would need continuous assistance. Extra-human reservoirs of Mycobacterium leprae, the relationship between leprosy and poverty, prevention of disabilities, lack of a reliable laboratory test to detect subclinical infection and a vaccine are also challenging issues.
Conclusion
The evidence base available to inform on leprosy elimination is highly positive with the availability of multi-drug therapy blister packs. There are concerns that leprosy was not the right disease to be targeted for elimination as there are no reliable diagnostic tests to detect subclinical infection including the lack of a vaccine, extra-human reservoirs (monkeys and armadillos), increase in the burden of child cases, no good epidemiological indicator as prevalence instead of incidence is used to measure elimination. Multi-drug therapy treats leprosy very well but there is no proof that it concurrently interrupts transmission. The high social stigma, prevention of disabilities, and the relationship between leprosy and poverty are still major concerns.
PMCID: PMC3215526  PMID: 22145052
Leprosy; elimination; multi-drug therapy; public health; eradication; epidemiology
3.  Internal Evaluation of National Leprosy Elimination Program in Tribal Gujarat 
Background:
The government launched a National Leprosy Eradication program in 1983, to eliminate leprosy from India. A Modified Leprosy Elimination Campaign was started with the view to early case detection and treatment. In April 2004, a vertical program of leprosy was merged with the general health services and case detection was conducted by the general health workers in India.
Materials and Methods:
Internal evaluation of leprosy was done in the Panchmanal district of Gujarat through a rapid survey of the 10 Primary Health Care units in the high and low endemic areas. Active and passive surveillance data and records were verified according to the indicators.
Results:
Analysis of the data and record verification revealed that there was a decrease in the prevalence rate of leprosy, but it had not reached the elimination status. The MB ratio had decreased, but the child ratio remained consistent for the last five years. The disability ratio had also decreased in five years.
Conclusion:
The National Leprosy Elimination Program had a favorable impact, but at the same time to reach the elimination status there was a need for more stringent Information, Education, and Communication (IEC) activities to be promoted in the community. Active surveillance should be initiated so that hidden cases are not missed in the community.
doi:10.4103/0970-0218.62574
PMCID: PMC2888341  PMID: 20606937
Evaluation; leprosy; prevalence rate
4.  Case Control Study to Determine the Factors Associated with Leprosy in the Sene District, Brong Ahafo Region of Ghana 
Ghana Medical Journal  2010;44(3):93-97.
Summary
Introduction
There are currently an estimated 10–12 million cases of leprosy in the world. In Sene District of the Brong Ahafo Region of Ghana the prevalence of leprosy is 2.4/10,000 of the population. Most of these cases are children, indicating that new infections are still occurring in the communities.
Objectives
To identify factors associated with leprosy in the Sene District in order to implement an effective strategy to eliminate leprosy from the district.
Design
Case-control study.
Method
The cases were selected from a register of active leprosy cases. Controls were matched for age, and sex. For every one case identified two controls were selected.
Results
Of the twenty four cases identified, eighteen (75%) were paucibacillary and six (25%) were multibacillary leprosy. Most of the leprosy lesions were found on the trunk (25%) and upper limbs (37.5%). 13(54.2%) of the cases were under twenty years old. From the study, contact with someone with leprosy in the same house is associated with having leprosy. (OR −3.4 95%CI 1.09–10.8 p=0.017). Not having BCG vaccination is associated with having leprosy (OR 11 95%CI 2.12–76.17)p=0.0005).
Conclusion
The findings confirm that close contact with a patient with leprosy facilitates transmission of M. leprae. To reduce leprosy in the Sene District there is the need to increase BCG vaccination coverage in children and ensure that all contacts of cases are thoroughly screened for the disease and treated. Health workers in the district need to be trained to identify leprosy lesions.
PMCID: PMC2996841  PMID: 21327012
Leprosy; case control study; M. leprae; transmission; Ghana
5.  Leprosy Scenario at a Tertiary Level Hospital in Delhi: A 5-year Retrospective Study 
Indian Journal of Dermatology  2015;60(1):55-59.
Background:
Leprosy has been officially eliminated from India since December, 2005; still, there are districts and blocks reporting high prevalence indicating ongoing transmission. The present study aimed at determining the current clinical profile of leprosy from a tertiary level hospital in Delhi.
Materials and Methods:
A retrospective, record-based study was carried out on patients diagnosed and registered in the leprosy clinic of a tertiary level teaching hospital in East district of Delhi (April 2007 to March 2012). Data regarding demographic details, clinical features, treatment started and complications was analyzed.
Results:
A total of 849 patients were registered over a 5-year period, with M: F ratio of 2.3:1. 9.3% were children (≤14 years). 54.3% patients were immigrants from adjoining states. Multibacillary leprosy was the most common clinical type (86.9%). Borderline tuberculoid leprosy was the most frequent morphologic type, seen in 56.3% followed by borderline-borderline (1.5%), borderline lepromatous (24.9%), lepromatous leprosy (8.1%), pure neuritic (8.1%), histoid and indeterminate leprosy (0.5% each). 37.4% patients presented in reaction (Type I in 30.4% cases and Type II in 7% cases). WHO grade II deformities were diagnosed in 37.9% with claw hand being the most common paralytic deformity (23.3% cases).
Conclusion:
Our study offers insight into the current status of the disease in an area of otherwise low prevalence. It is seen that despite statistical elimination, multibacillary disease, leprosy reactions and deformities are commonly seen as presenting manifestations, in contrast to national projected trends. Delhi's unique demography with a high degree of migrant workers, presenting to our center (near border location) could be a possible contributing factor towards these aberrations. It highlights the need for continuation of targeted leprosy control activities and active case detection.
doi:10.4103/0019-5154.147793
PMCID: PMC4318064  PMID: 25657398
Grade 2 deformity; leprosy reactions; multibacillary disease
6.  A Comparative Study of the Quality of Life, Knowledge, Attitude and Belief About Leprosy Disease Among Leprosy Patients and Community Members in Shantivan Leprosy Rehabilitation centre, Nere, Maharashtra, India 
Background:
Leprosy a chronic infectious affliction, is a communicable disease that posses a risk of permanent and progressive disability. The associated visible deformities and disabilities have contributed to the stigma and discrimination experienced by leprosy patients, even among those who have been cured.
Aims and Objectives:
1) To assess the knowledge, attitude and belief about leprosy in leprosy patients compared with community members. 2) To find the perceived stigma among leprosy patients. 3). To evaluate the quality of life in leprosy patients as compared to community members using WHO Quality of Life assessment questionaire (WHOQOL- BREF).
Materials and Methods:
A cross sectional study was conducted at Leprosy Rehabilitation Centre, Shantivan, Nere in Panvel Taluka, district Raigad from October – December 2009. A pre-designed and pre-structured questionaire was used to evaluate knowledge, attitude and perceived stigma among leprosy patients and community members. WHO Quality of life questionaire (WHOQOL-BREF) was used to assess quality of life in leprosy patients and controls. Data analysis was done with the help of SPSS package.
Result:
Among the cases and control, 43.13% of cases were aware that leprosy is an infectious disease compared to 20.69% of control. 68.62% of cases had knowledge of hypopigmented patches being a symptom of leprosy compared to the 25.86% in control. There was overall high level of awareness about disease, symptoms, transmission and curability in leprosy patients as compared to control. Among control group, 43.10% of population said that they would not like food to be served by leprosy patients as compared to 13.73% in study group. It was seen that the discrimination was much higher in female leprosy patients as compared to male leprosy patients. The mean quality of life scores for cases was significantly lower than those for control group in physical and psychological domain but not in the social relationship and environmental domain. The mean quality of life scores for male cases were lower in each domain as compared to male control group but the difference was not significant except in the physical and enviornmental domain. The mean quality of life scores for female cases were lower in each domain as compared to female control group and the difference was not significant except in the psychological domain.
Conclusions:
There was a significant difference in physical domain in male leprosy patients and psychological domain in female leprosy patients as compared with their respective gender controls. The leprosy patients were more aware about the infectious nature of the disease, symptoms, transmission, and curability than the control group. A negative attitude was seen towards the leprosy patients in the society.
doi:10.4103/0974-777X.91063
PMCID: PMC3249995  PMID: 22224003
Discrimination; KAP; Leprosy; Perceived stigma; Quality of life; Stigma
7.  Comparing the Clinical and Histological Diagnosis of Leprosy and Leprosy Reactions in the INFIR Cohort of Indian Patients with Multibacillary Leprosy 
Background
The ILEP Nerve Function Impairment in Reaction (INFIR) is a cohort study designed to identify predictors of reactions and nerve function impairment in leprosy. The aim was to study correlations between clinical and histological diagnosis of reactions.
Methodology/Principal Findings
Three hundred and three newly diagnosed patients with World Health Organization multibacillary (MB) leprosy from two centres in India were enrolled in the study. Skin biopsies taken at enrolment were assessed using a standardised proforma to collect data on the histological diagnosis of leprosy, leprosy reactions and the certainty level of the diagnosis. The pathologist diagnosed definite or probable Type 1 Reactions (T1R) in 113 of 265 biopsies from patients at risk of developing reactions whereas clinicians diagnosed skin only reactions in 39 patients and 19 with skin and nerve involvement. Patients with Borderline Tuberculoid (BT) leprosy had a clinical diagnosis rate of reactions of 43% and a histological diagnosis rate of 61%; for patients with Borderline Lepromatous (BL) leprosy the clinical and histological diagnosis rates were 53.7% and 46.2% respectively. The sensitivity and specificity of clinical diagnosis for T1R was 53.1% and 61.9% for BT patients and 61.1% and 71.0% for BL patients. Erythema Nodosum Leprosum (ENL) was diagnosed clinically in two patients but histologically in 13 patients. The Ridley-Jopling classification of patients (n = 303) was 42.8% BT, 27.4% BL, 9.4% Lepromatous Leprosy (LL), 13.0% Indeterminate and 7.4% with non-specific inflammation. This data shows that MB classification is very heterogeneous and encompasses patients with no detectable bacteria and high immunological activity through to patients with high bacterial loads.
Conclusions/Significance
Leprosy reactions may be under-diagnosed by clinicians and increasing biopsy rates would help in the diagnosis of reactions. Future studies should look at sub-clinical T1R and ENL and whether they have impact on clinical outcomes.
Author Summary
Leprosy affects skin and peripheral nerves. Although we have antibiotics to treat the mycobacterial infection, the accompanying inflammation is a major part of the disease process. This can worsen after starting antibacterial treatment with episodes of immune mediated inflammation, so called reactions. These are associated with worsening of nerve damage. However, diagnosing these reactions is not straightforward. They can be diagnosed clinically by examination or by microscopic examination of the skin biopsies. We studied a cohort of 303 newly diagnosed leprosy patients in India and compared the diagnosis rates by clinical examination and microscopy and found that the microscopic diagnosis has higher rates of diagnosis for both types of reaction. This suggests that clinicians and pathologists have different thresholds for diagnosing reactions. More work is needed to optimise both clinical and pathological diagnosis. In this cohort 43% of patients had Borderline Tuberculoid leprosy, an immunologically active type, and 20% of the biopsies showed only minimal inflammation, perhaps these patients had very early disease or self-healing. The public health implication of this work is that leprosy centres need to be supported by pathologists to help with the clinical management of difficult cases.
doi:10.1371/journal.pntd.0001702
PMCID: PMC3383736  PMID: 22745841
8.  Deformities due to Leprosy in Children under Fifteen Years Old as an Indicator of Quality of the Leprosy Control Programme in Brazilian Municipalities 
Journal of Tropical Medicine  2013;2013:812793.
The present study aims at analysing the degree of deformity in leprosy cases diagnosed in children under 15 years old and its relationship with operational and epidemiological factors. This epidemiological cross-sectional study was carried out at municipalities of three microregions in a Brazilian hyperendemic area. Data between 1998 and 2010 was collected from the Information System for Notifiable Diseases database. The average coefficient of detection was 32.96/100.000 inhabitants; 7.61% of new cases were diagnosed in children under 15 years old; 5% in this age group were grade 2 deformity at diagnosis. Prevalence of leprosy cases in children under 15 years old with deformity was higher in males (PR = 2.65;P = 0.032; CI 95%: 1.09–6.45) and in multibacillary patients (PR = 14.68;P < 0.001; CI 95%: 3.54–60.87) and lower when the detection mode was passive (PR = 0.73,P = 0.47, CI 95%: 0.31–1.73). Such context suggests high transmissibility and early exposure to Mycobacterium leprae since a lot of cases were diagnosed in children under fifteen years old and the incubation period of the leprosy bacillus varies from 02 to 07 years. This situation contributes to maintaining the chain of disease transmission in the area and indicates that health care services should intensify leprosy control.
doi:10.1155/2013/812793
PMCID: PMC3614053  PMID: 23577038
9.  Integration of Leprosy Elimination into Primary Health Care in Orissa, India 
PLoS ONE  2009;4(12):e8351.
Background
Leprosy was eliminated as a public health problem (<1 case per 10,000) in India by December 2005. With this target in sight the need for a separate vertical programme was diminished. The second phase of the National Leprosy Eradication Programme was therefore initiated: decentralisation of the vertical programme, integration of leprosy services into the primary health care (PHC) system and development of a surveillance system to monitor programme performance.
Methodology/Principal Findings
To study the process of integration a qualitative analysis of issues and perceptions of patients and providers, and a review of leprosy records and registers to evaluate programme performance was carried out in the state of Orissa, India. Program performance indicators such as a low mean defaulter rate of 3.83% and a low-misdiagnosis rate of 4.45% demonstrated no detrimental effect of integration on program success. PHC staff were generally found to be highly knowledgeable of diagnosis and management of leprosy cases due to frequent training and a support network of leprosy experts. However in urban hospitals district-level leprosy experts had assumed leprosy activities. The aim was to aid busy PHC staff but it also compromised their leprosy knowledge and management capacity. Inadequate monitoring of a policy of ‘new case validation,’ in which MDT was not initiated until primary diagnosis had been verified by a leprosy expert, may have led to approximately 26% of suspect cases awaiting confirmation of diagnosis 1–8 months after their initial PHC visit.
Conclusions/Significance
This study highlights the need for effective monitoring and evaluation of the integration process. Inadequate monitoring could lead to a reduction in early diagnosis, a delay in initiation of MDT and an increase in disability rates. This in turn could reverse some of the programme's achievements. These findings may help Andhra Pradesh and other states in India to improve their integration process and may also have implications for other disease elimination programmes such as polio and guinea worm (dracunculiasis) as they move closer to their elimination goals.
doi:10.1371/journal.pone.0008351
PMCID: PMC2791232  PMID: 20020051
10.  Patients' Perceptions on the Performance of a Local Health System to Eliminate Leprosy, Paraná State, Brazil 
Background
In Brazil, leprosy has been listed among the health priorities since 2006, in a plan known as the “Pact for life” (Pacto pela Vida). It is the sole country on the American continent that has not reached the global goal of disease elimination. Local health systems face many challenges to achieve this global goal. The study aimed to investigate how patients perceive the local health system's performance to eliminate leprosy and whether these perceptions differ in terms of the patients' income.
Methodology/Principal Findings
A cross-sectional study was conducted in Londrina, State of Paraná, Brazil. Interviews were performed with the leprosy patients. The local health system was assessed through a structured and adapted tool, considering the domains judged as good quality of health care. The authors used univariate, bivariate and multivariate analyses. One hundred and nineteen patients were recruited for the study, 50.4% (60) of them were male, 54.0% (64) were between 42 and 65 years old and 66.3% (79) had finished elementary school. The results showed that patients used the Primary Health Care service near their place of residence but did not receive the leprosy diagnosis there. Important advances of this health system were verified for the elimination of leprosy, verifying protocols for good care delivery to the leprosy patients, but these services did not develop collective health actions and did not engage the patients' family members and community.
Conclusions/Significance
The patients' difficulty was observed to have access to the diagnosis and treatment at health services near their homes. Leprosy care is provided at the specialized level, where the patients strongly bond with the teams. The care process is individual, with limited perspectives of integration among the health services for the purpose of case management and social mobilization of the community to the leprosy problem.
Author Summary
Brazil still has not achieved the goal of leprosy elimination established by World Health Organization. The diagnosis and treatment of leprosy is easy and the country is striving to fully integrate leprosy services into existing general health services. Access to information, diagnosis and treatment with multidrug therapy (MDT) remain key elements in the strategy to eliminate the disease as a public health problem, defined as reaching a prevalence of less than one leprosy case per 10,000 population. Thus, this study aimed to investigate the performance of a local health system to eliminate leprosy through a cross-sectional study with leprosy patients. One hundred and nineteen patients were recruited for the study, 50.4% of them (60) were male, 54.0% (64) were between 42 and 65 years old and 66.3% (79) had finished elementary school. The health teams have invested only in the individual perspective and they do not coordinate the patients' care and, also, their practices are fragmented without perspectives of integration between different health services and social mobilization, an essential condition for the development of an effective and responsive system.
doi:10.1371/journal.pntd.0003324
PMCID: PMC4238994  PMID: 25412349
11.  Is leprosy blindness avoidable? The effect of disease type, duration, and treatment on eye damage from leprosy in Uganda. 
AIMS--The study was designed to measure the prevalence, range, and severity of eye involvement in leprosy patients; to relate this to disease type, duration, and treatment to identify risk factors; and to provide practical guidelines for programme managers and field staff on the prevention of blindness. METHODS--The visual outcome was assessed in a population based sample of patients in Kasese District, Uganda followed for up to two decades, and related to disease features and treatment. A total of 678 patients responded to an invitation out of 2715 registered since 1973. RESULTS--Low vision was present in 4.4% of people and blindness in 1.3%, with 1.5% and 0.6% respectively being due to leprosy. Some 12.4% of patients had iritis, of whom 33% had visual loss in one or both eyes, 3.7% of patients had lagophthalmos, and 11.7% had lens opacity. For multi-bacillary (PB) cases, the adjusted odds ratios were: for iritis 4.6 (95% CI 2.6-8.2), for lagophthalmos 1.4 (0.6-3.2), and for lens opacity 1.7 (1.0-3.0). Potentially sight threatening (PST) lesions were present in 16.8% of patients (95% CI 14.0-19.6). CONCLUSION--Levels of eye involvement in this study are low compared with many surveys. Visual loss is uncommon and is more often caused by other diseases; in the present era of multidrug therapy (MDT) it is very unlikely to be caused by leprosy. It is more common with advancing age. PST lesions, especially iritis, may occur in both PB and MB cases, even if the diagnosis of leprosy is made early and MDT started immediately; they may occur also after completion of MDT. But eye complications need not proceed to loss of sight if treated promptly, and blindness can be avoided. Training of front line staff is therefore crucial.
PMCID: PMC505073  PMID: 7703204
12.  Epidemiologic and clinicopathologic aspects of Leprosy in Dakar; evaluation of 73 new cases 
Dermatology Reports  2011;3(2):e18.
Hundreds of new leprosy cases are still diagnosed in Dakar despite all the efforts in the struggle by the national program for elimination of leprosy by the Institute of Applied Leprosy in Dakar. The aim of our study was to evaluate the epidemiological, clinicopathological and outcome of new cases of leprosy. A prospective study was conducted over a period of one year listing all new cases of leprosy based on clinical diagnosis, bacteriology and histology. 73 new cases were recorded. The sex ratio was 1.5 and the mean age of 39.5 years. Children aged from 0 to 15 years old represented 12%. The clinical forms were rated in order of decreasing frequency Borderline 47.94%, 30.13% lepromatous lepromatous, indeterminate 8.21, borderline lepromatous 6.84, TT: 5.47%, 1.36 and neurological bb%. Neurological signs were enlarged nerve in 50 cases, a neurological deficit in 16 cases and a sensitive deficit in 16 cases. The complications were burns and ulcerations in 10 cases, a claw in 7 cases, a reversal reaction in 7 cases, erythema nodosum in 4 cases and neuritis in 8 cases. The number of new cases mutilated was 24.65%. The smear was positive in 42% and histology contribution in 91.37% of cases. Our study highlights the significant number of patients with multibacillary contagious, affected children, the high proportion of disability grade 2/OMS reflecting the delay in diagnosis. This delay is due to ignorance, to traditional treatments and low socio-economic status and lack of trained diagnostic teams in different areas apart from referral centres.
doi:10.4081/dr.2011.e18
PMCID: PMC4211520  PMID: 25386270
leprosy; Senegal.
13.  Spatial Analysis Spotlighting Early Childhood Leprosy Transmission in a Hyperendemic Municipality of the Brazilian Amazon Region 
Background
More than 200,000 new cases of leprosy were reported by 105 countries in 2011. The disease is a public health problem in Brazil, particularly within high-burden pockets in the Amazon region where leprosy is hyperendemic among children.
Methodology
We applied geographic information systems and spatial analysis to determine the spatio-temporal pattern of leprosy cases in a hyperendemic municipality of the Brazilian Amazon region (Castanhal). Moreover, we performed active surveillance to collect clinical, epidemiological and serological data of the household contacts of people affected by leprosy and school children in the general population. The occurrence of subclinical infection and overt disease among the evaluated individuals was correlated with the spatio-temporal pattern of leprosy.
Principal Findings
The pattern of leprosy cases showed significant spatio-temporal heterogeneity (p<0.01). Considering 499 mapped cases, we found spatial clusters of high and low detection rates and spatial autocorrelation of individual cases at fine spatio-temporal scales. The relative risk of contracting leprosy in one specific cluster with a high detection rate is almost four times the risk in the areas of low detection rate (RR = 3.86; 95% CI = 2.26–6.59; p<0.0001). Eight new cases were detected among 302 evaluated household contacts: two living in areas of clusters of high detection rate and six in hyperendemic census tracts. Of 188 examined students, 134 (71.3%) lived in hyperendemic areas, 120 (63.8%) were dwelling less than 100 meters of at least one reported leprosy case, 125 (66.5%) showed immunological evidence (positive anti-PGL-I IgM titer) of subclinical infection, and 9 (4.8%) were diagnosed with leprosy (8 within 200 meters of a case living in the same area).
Conclusions/Significance
Spatial analysis provided a better understanding of the high rate of early childhood leprosy transmission in this region. These findings can be applied to guide leprosy control programs to target intervention to high risk areas.
Author Summary
Leprosy can lead to physical disabilities and deformities if not diagnosed and treated early. Even today, the disease affects more than 200,000 people per year, particularly the poorest people from developing countries, such as India, Brazil and Indonesia. Cases among children <15 years old have been used as an important indicator of recent transmission in the community. Recently, geographic information systems and spatial analysis have become important tools for epidemiology, helping to understand the transmission dynamics of several diseases. In this work, we determined the spatial and temporal distribution of leprosy in a hyperendemic municipality of the Brazilian Amazon region. In association with clinical, epidemiological and serological data of household contacts and school children in the general population, we further correlated the occurrence of subclinical infection and overt disease with the distribution of reported cases. We identified heterogeneity in the distribution of leprosy, with significant clusters of high and low detection rates. Our analysis revealed that children with leprosy or those harboring subclinical infection were in close proximity to spatial and temporal clusters of leprosy cases. These findings can be applied to guide leprosy control programs to target intervention more systematically to areas where the risk of leprosy is high.
doi:10.1371/journal.pntd.0002665
PMCID: PMC3916250  PMID: 24516679
14.  Multiplex PCR technique could be an alternative approach for early detection of leprosy among close contacts - a pilot study from India 
BMC Infectious Diseases  2010;10:252.
Background
Implementation of Multi drug Therapy (MDT) regimen has resulted in the decline of the total number of leprosy cases in the world. Though the prevalence rate has been declining, the incidence rate remains more or less constant and high in South East Asian countries particularly in India, Nepal, Bangladesh, Pakistan and Srilanka. Leprosy, particularly that of multibacillary type spreads silently before it is clinically detected. An early detection and treatment would help to prevent transmission in the community. Multiplex PCR (M-PCR) technique appears to be promising towards early detection among contacts of leprosy cases.
Methods
A total of 234 paucibacillary (PB) and 205 multibacillary (MB) leprosy cases were studied in a community of an endemic area of Bankura district of West Bengal (Eastern India). They were assessed by smear examination for acid-fast bacilli (AFB) and M-PCR technique. These patients were treated with Multidrug Therapy (MDT) as prescribed by WHO following detection. A total of 110 MB and 72 PB contacts were studied by performing M-PCR in their nasal swab samples.
Results
83.4% of MB patients were observed to be positive by smear examination for AFB and 89.2% by M-PCR. While 22.2% of PB patients were found to be positive by smear examination for AFB, 80.3% of these patients were positive by M-PCR. Among leprosy contacts (using M-PCR), 10.9% were found to be positive among MB contacts and 1.3% among PB contacts. Interestingly, two contacts of M-PCR positive MB cases developed leprosy during the period of two years follow up.
Conclusion
The M-PCR technique appears to be an efficient tool for early detection of leprosy cases in community based contact tracing amongst close associates of PB and MB cases. Early contact tracing using a molecular biology tool can be of great help in curbing the incidence of leprosy further.
doi:10.1186/1471-2334-10-252
PMCID: PMC2942881  PMID: 20735843
15.  The Challenge of Producing Skin Test Antigens with Minimal Resources Suitable for Human Application against a Neglected Tropical Disease; Leprosy 
True incidence of leprosy and its impact on transmission will not be understood until a tool is available to measure pre-symptomatic infection. Diagnosis of leprosy disease is currently based on clinical symptoms, which on average take 3–10 years to manifest. The fact that incidence, as defined by new case detection, equates with prevalence, i.e., registered cases, suggests that the cycle of transmission has not been fully intercepted by implementation of multiple drug therapy. This is supported by a high incidence of childhood leprosy. Epidemiological screening for pre-symptomatic leprosy in large endemic populations is required to facilitate targeted chemoprophylactic interventions. Such a test must be sensitive, specific, simple to administer, cost-effective, and easy to interpret. The intradermal skin test method that measures cell-mediated immunity was explored as the best option. Prior knowledge on skin testing of healthy subjects and leprosy patients with whole or partially fractionated Mycobacterium leprae bacilli, such as Lepromin or the Rees' or Convit' antigens, has established an acceptable safety and potency profile of these antigens. These data, along with immunoreactivity data, laid the foundation for two new leprosy skin test antigens, MLSA-LAM (M. leprae soluble antigen devoid of mycobacterial lipoglycans, primarily lipoarabinomannan) and MLCwA (M. leprae cell wall antigens). In the absence of commercial interest, the challenge was to develop these antigens under current good manufacturing practices in an acceptable local pilot facility and submit an Investigational New Drug to the Food and Drug Administration to allow a first-in-human phase I clinical trial.
Author Summary
Despite reaching the global elimination target for leprosy, the need for a diagnostic tool to detect pre-symptomatic disease remains. Transmission has not been completely intercepted despite over 30 years of extensive curative treatment. With limited resources, two new leprosy skin test antigens, MLSA-LAM and MLCwA, suitable for human application were developed and manufactured in a local pilot plant. Requirements for manufacturing and clinical testing were met and an Investigational New Drug was established with the Food and Drug Administration to test both antigens in a phase I clinical trial for safety in a non-endemic region for leprosy and a phase II clinical trial for safety and efficacy in an endemic region for leprosy.
doi:10.1371/journal.pntd.0002791
PMCID: PMC4038479  PMID: 24874086
16.  TRANSMISSION OF LEPROSY IN QIUBEI COUNTY, YUNNAN, CHINA: INSIGHTS FROM AN EIGHT YEAR MOLECULAR EPIDEMIOLOGY INVESTIGATION 
Leprosy continues to be endemic in parts of China. To track the occurrence of leprosy and determine at risk communities, molecular strain typing based on variable number of tandem repeats (VNTRs) was applied in Qiubei County, Wenshan Prefecture, Yunnan Province of the People’s Republic of China, a multiethnic region that is home to four predominant ethnic minorities. A previous study, conducted between 2002 and 2005, provided the first descriptions of Mycobacterium leprae strains in the region. M. leprae strains in Qiubei are highly conserved, so only sufficiently polymorphic loci can distinguish strains. A balance between mutation rate and loci stability is needed, so that secondary transmissions can be identified as genotypic matches. The long incubation period of leprosy necessitated an extension of the study to assess the validity of VNTR typing and observe allelic shifts in the same multiethnic population. From 2006 to early 2010 the extension was performed to yield a cumulative total of 164 enrolled patients and 130 skin samples suitable for VNTR typing. Patient demographic information revealed that the case detection rate among certain minority populations in the county is considerably higher than the national rate. Cluster analysis of allele frequencies showed similar strain types within family groups and neighboring townships. Allele frequencies were not found to significantly differ between genders or clinical presentations. The percentage of cases showing near-matching genotypes varied with geography; showing a considerably higher rate in the northern townships. The northern townships continue to show strain types falling into the groups previously defined. Southern genotypes were distinct from those in the north, but clonal genetic relationships were indiscernible in the south. Social interactions and the physical, residential and occupational environments may be more conducive to transmission of community strains in the north.
doi:10.1016/j.meegid.2010.11.014
PMCID: PMC3085323  PMID: 21129505
Leprosy; Molecular Epidemiology; Strain typing; VNTR
17.  Risk of developing disability in pre and post-multidrug therapy treatment among multibacillary leprosy: Agra MB Cohort study 
BMJ Open  2012;2(2):e000361.
Objectives
If leprosy is a public health problem, it is due to the disabilities it causes. Surprisingly little is known about the risk of disabilities. Even now, mainly cross-sectional studies report disability prevalence. The present study aims to report the risk of disability in pre and post-WHO multidrug therapy (MDT) in multibacillary leprosy patients and to assess the extent of the incidence of disability.
Methods
The study design is prospective and the setting is an institutional field area. Patients were detected during 2001–6 field surveys. Of the 289 multibacillary patients, 146 completed the study. Both sexes were involved. The primary outcome planned was to study cure of disease, relapses and disability in patients receiving MDT. The secondary outcome was to measure reaction and default. Assessment was done clinically. Data have been analysed using SPSS software, logistic, survival analysis was performed and the χ2 test of significance was used.
Results
An important risk factor was found to be three or more nerves involved with odds of 3.73 (1.24–11.2), and delay in treatment; 2.27 (1.04–4.96) at the pre-MDT stage and three or more nerves involved with odds of 2.81 (1.0–7.9) at the post-MDT stage. The incidence of disability was found to be 2.74/100 person-years; 2.69 in the MDT arm and 2.84 in defaulters, with slightly higher disability among early defaulters (3.08) than among late defaulters (2.30). The study suggests that the incidence of disability could be slightly higher if treatment is not completed.
Conclusion
Early treatment for leprosy is a must for reducing the risk of disability, and treatment delay would increase the risk of disability. It is important to note that the incidence of disability between defaulters and those completing treatment was not found to be significantly different.
Article summary
Article focus
What are the risk factors associated with disability at the pre-MDT and post-MDT stage?
What is the risk of disability among leprosy patients, patients completing treatment versus defaulters?
Do early defaulters have a higher incidence of disability than late defaulters?
Key messages
This study clearly demonstrates that risk factors for disability at detection and in a prospective cohort are the same, ie, an increasing number of nerves thickening. It also reveals that the incidence of disability although high among defaulters (2.84/100 person-years) is not significantly higher than in those completing treatment (2.42/100 person-years); nor does it differ significantly among early versus late defaulters (3.08 vs 2.30). In addition, it shows that treatment with ROM has much better prevention than in MDT groups. All this together implies that even a few months of treatment could be as good as completing treatment as far as the development of disability is concerned, but treatment must be started.
Strength and limitations of this study
The strength of the study is that it is based on a closely followed prospective cohort for a good length of time and patients were clinically assessed and monitored. However, one limitation could be that the ROM arm could not be completed due to WHO withdrawal. This could have provided more comparable data.
doi:10.1136/bmjopen-2011-000361
PMCID: PMC3330256  PMID: 22454186
18.  Disability in people affected by leprosy: the role of impairment, activity, social participation, stigma and discrimination 
Global Health Action  2012;5:10.3402/gha.v5i0.18394.
Background
Leprosy-related disability is a challenge to public health, and social and rehabilitation services in endemic countries. Disability is more than a mere physical dysfunction, and includes activity limitations, stigma, discrimination, and social participation restrictions. We assessed the extent of disability and its determinants among persons with leprosy-related disabilities after release from multi drug treatment.
Methods
We conducted a survey on disability among persons affected by leprosy in Indonesia, using a Rapid Disability Appraisal toolkit based on the International Classification of Functioning, Disability and Health. The toolkit included the Screening of Activity Limitation and Safety Awareness (SALSA) scale, Participation Scale, Jacoby Stigma Scale (anticipated stigma), Explanatory Model Interview Catalogue (EMIC) stigma scale and Discrimination assessment. Community members were interviewed using a community version of the stigma scale. Multivariate linear regression was done to identify factors associated with social participation.
Results
Overall 1,358 persons with leprosy-related disability (PLD) and 931 community members were included. Seventy-seven percent of PLD had physical impairments. Impairment status deteriorated significantly after release from treatment (from 59% to 77%). Around 60% of people reported activity limitations and participation restrictions and 36% anticipated stigma. As for participation restrictions and stigma, shame, problems related to marriage and difficulties in employment were the most frequently reported problems. Major determinants of participation were severity of impairment and level of education, activity and stigma. Reported severity of community stigma correlated with severity of participation restrictions in the same districts.
Discussion
The majority of respondents reported problems in all components of disability. The reported physical impairment after release from treatment justifies ongoing monitoring to facilitate early prevention. Stigma was a major determinant of social participation, and therefore disability. Stigma reduction activities and socio-economic rehabilitation are urgently needed in addition to strategies to reduce the development of further physical impairment after release from treatment.
doi:10.3402/gha.v5i0.18394
PMCID: PMC3402069  PMID: 22826694
leprosy; disability; impairment; activity; participation; ICF; stigma; discrimination
19.  Leprosy among Patient Contacts: A Multilevel Study of Risk Factors 
Background
This study aimed to evaluate the risk factors associated with developing leprosy among the contacts of newly-diagnosed leprosy patients.
Methodology/Principal Findings
A total of 6,158 contacts and 1,201 leprosy patients of the cohort who were diagnosed and treated at the Leprosy Laboratory of Fiocruz from 1987 to 2007 were included. The contact variables analyzed were sex; age; educational and income levels; blood relationship, if any, to the index case; household or non-household relationship; length of time of close association with the index case; receipt of bacillus Calmette-Guérin (BGG) vaccine and presence of BCG scar. Index cases variables included sex, age, educational level, family size, bacillary load, and disability grade. Multilevel logistic regression with random intercept was applied. Among the co-prevalent cases, the leprosy-related variables that remained associated with leprosy included type of household contact, [odds ratio (OR) = 1.33, 95% confidence interval (CI): 1.02, 1.73] and consanguinity with the index case, (OR = 1.89, 95% CI: 1.42–2.51). With respect to the index case variables, the factors associated with leprosy among contacts included up to 4 years of schooling and 4 to 10 years of schooling (OR = 2.72, 95% CI: 1.54–4.79 and 2.40, 95% CI: 1.30–4.42, respectively) and bacillary load, which increased the chance of leprosy among multibacillary contacts for those with a bacillary index of one to three and greater than three (OR = 1.79, 95% CI: 1.19–2.17 and OR: 4.07–95% CI: 2.73, 6.09), respectively. Among incident cases, household exposure was associated with leprosy (OR = 1.96, 95% CI: 1.29–2.98), compared with non-household exposure. Among the index case risk factors, an elevated bacillary load was the only variable associated with leprosy in the contacts.
Conclusions/Significance
Biological and social factors appear to be associated with leprosy among co-prevalent cases, whereas the factors related to the infectious load and proximity with the index case were associated with leprosy that appeared in the incident cases during follow-up.
Author Summary
Leprosy is an infectious disease that can lead to physical disabilities, social stigma, and great hardship. Transmitted from person to person, it is still endemic in developing countries, like Brazil and India. Effective treatment has been available since 1960, but early diagnosis of the disease remains the most effective way to stop the transmission chain and avoid late diagnoses and subsequent disabilities. Knowledge of the risk factors for leprosy can facilitate early detection; therefore, our study aimed to investigate the factors presented by leprosy patients and their contacts, who are considered at highest risk of contracting the disease. We studied 6,158 contacts of 1,201 patients under surveillance from 1987 to 2007 in a Public Health Care Center in the City of Rio de Janeiro, Brazil. We evaluated the ways patient and contact demographics and epidemiological characteristics were associated with the detection of leprosy. Statistical analyses took into account both individual and group characteristics and their interrelationships. The main characteristics facilitating the contraction of leprosy among contacts were shown to be consanguinity and household association. Conversely, the bacillary load index of leprosy patients was the principle factor leading to disease among their contacts.
doi:10.1371/journal.pntd.0001013
PMCID: PMC3057944  PMID: 21423643
20.  Medical Rehabilitation of Leprosy Patients Discharged Home in Abia and Ebonyi States of Nigeria 
Oman Medical Journal  2011;26(6):393-398.
Objectives
To examine the extent to which medical coverage is available to discharged leprosy patients in communities. Evidence has shown that after care services, follow-up visits and national disease prevention programs are important components of medical rehabilitation to leprosy patients discharged home after treatment. Denying them accessibility to these services could expose them to multiple disabilities as well as several disease conditions including HIV/AIDS. These adverse health conditions could be averted if health workers extend healthcare services to discharged leprosy patients. This study was conducted to examine the extent to which discharged leprosy patients have access to healthcare services in the communities.
Methods
All 33 leprosy patients who were fully treated with multi-drug therapy (MDT) and discharged home in the two leprosy settlements in Abia and Ebonyi States of Nigeria were included in this study. The list of discharged leprosy patients studied and their addresses were provided by the leprosy settlements where they were treated. Also, snowball-sampling method was used to identify some of the leprosy patients whose addresses were difficult to locate in the communities. Instruments for data collection were questionnaire, interview guide and checklist. These were administered because respondents were essentially those with no formal education. Analysis of data was done quantitatively and qualitatively.
Results
Findings showed that 20 (60.6%) of discharged patients did not receive health programs like HIV/AIDS prevention or family planning. Also, follow-up visits and after-care services were poor. About 14 (42.4%) of the patients live in dirty and overcrowded houses. On the whole, discharged patients were poorly medically rehabilitated (mean score: 4.7±1.1 out of total score of 7).
Conclusion
Denying discharged leprosy patients opportunity of accessing health care services could increase prevalence of infectious diseases including HIV/AIDS among them. There is need to extend national prevention programs, follow-up visits, after-care services and free treatment to discharged patients in the communities.
doi:10.5001/omj.2011.102
PMCID: PMC3251206  PMID: 22253946
Leprosy; Prophylaxis; Discharged patients; Disability; HIV/AIDS; Family planning
21.  A Retrospective Study of the Epidemiology of Leprosy in Cebu: An Eleven-Year Profile 
Background
Cebu has been one of the most leprosy endemic areas in the Philippines. Despite the high coverage rates of multiple drug therapy (MDT) and high BCG-vaccine coverage in children, leprosy control authorities believe that leprosy transmission and incidence (as evidence by continuing new case detection in both adults and children) have not declined as expected, once leprosy had been eliminated.
In response to the concerns communicated by the authorities regarding ongoing leprosy transmission in Cebu, this study aims to examine the evidence for the hypothesized ongoing transmission, both in children and adults. Furthermore, it will be assessed which groups and areas are experiencing a continuing risk of leprosy infection; this can form a starting point for more targeted approaches to leprosy control.
Methodology & Principal Findings
Case records from 2000–2010 were retrospectively collected from the Leonard Wood Memorial Clinic archives, and all other clinics on the island where leprosy was treated. Between 2000 and 2010, 3288 leprosy cases were detected. The overall five year case notification rate (CNR) dropped significantly from 47.35 (2001–2005) to 29.21 cases (2006–2010) per 100.000 population. Smaller CNRs were reported for children; however the decline in child-CNR over the same period was minimal. Furthermore, no increase in median age of notification in children or adults was found between 2000 and 2010. Population-adjusted clustering of leprosy cases was mainly detected in urban and peri-urban areas.
Conclusions & Significance
Although the overall CNR declined significantly, CNR seems to be rather static in lower risk populations and areas. Cases are mainly found in urban areas, however CNRs in these areas decline at a much faster rate than in the lower endemic rural areas. A similar situation was found when comparing adults and children: CNRs observed in children were lower than in adults, but further decline (and elimination) of these childhood CNRs was found to be difficult. Moreover, the median age of notification in children has remained stable, suggesting transmission is still on-going.
It is unclear why many years of good MDT-coverage and a gradual decline in CNR have not been accompanied by evidence of reduced transmission, especially beyond a certain threshold level of case notification. We believe that a new approach to leprosy control is required to tackle transmission more directly. The most promising approach may involve chemoprophylaxis and/or immunoprophylaxis interventions, targeted at high risk (urban) areas and groups such as household contacts, followed by a different approach once decline in CNR starts to level off. Identified clusters and trends can form the starting point for implementing this approach.
Author Summary
The island of Cebu is one of the most leprosy-endemic areas in the Philippines. Multiple drug therapy (MDT), improved BCG-vaccine coverage and active case finding have significantly lowered the adult case notification rates (CNRs), but the CNR in children (which is a proxy indicator of ongoing transmission) seems to be more static over the last decade (2000–2010). The long incubation period of leprosy, hampers determination of time of infection, however one would expect the median age of notification in children to increase when transmission decreases, as younger subjects would have a lower risk of infection: in this study no significant changes in median age were found between 2000–2010. Furthermore, leprosy seems to be mainly confined to urban areas, where nonetheless the measured decrease in CNR is much larger than in less endemic rural areas. It is unclear why the significant decline in CNR have not been accompanied by evidence of reduced transmission and why CNR seem to level off beyond a certain threshold level. We believe that more targeted approaches (e.g. focused on household contacts in urban areas) involving chemoprophylaxis and/or immunoprophylaxis, followed by a specific approach for lower CNRs, are required to tackle leprosy more directly.
doi:10.1371/journal.pntd.0002444
PMCID: PMC3777917  PMID: 24069495
22.  Leprosy elimination: A myth busted 
Background:
Leprosy is mainly a chronic infectious disease caused by Mycobacterium leprae. The disease mainly affects the skin, the peripheral nerves, mucosa of the upper respiratory tract and eyes. Though the target of leprosy elimination was achieved at national level in 2006 even then a large proportion of leprosy cases reported globally still constitute from India.
Aim and Objective:
To study the clinico-epidemiological profile of new cases of leprosy in a rural tertiary hospital.
Materials and Methods:
Thirty-five newly diagnosed cases of leprosy presented in out-patient/admitted in the department of Dermatology, Venereology and Leprosy (between September 2012 and August 2013) were included in the study. Detailed history regarding leprosy, deformity, sensory loss, skin smear for AFB and histopathological examination were done in every patient.
Results:
The incidence was more in age group of 20 to 39 years (48.57%) and 40 to 59 years (37.14%). 68.57% were males. 48.57% cases were found to have facial deformity and ear lobe thickening was found to be pre-dominant form of facial deformity. Ulnar (88.87%) and common peroneal nerve (34.28%) were the most commonly involved nerves. The split skin smear examination was found to be positive in 27 out of 35 cases. On histopathological examination 10 patients (28.57%) were of lepromatous pole (LL), 4 (11.43%) were of indeterminate, 6 (17.14%) were of tuberculoid type (TT), 4 BT (11.4%) and 1 BL type (2.8%).
Conclusions:
This study helps in concluding that leprosy is still not eliminated. Active surveillance is still needed to detect the sub-clinical cases and undiagnosed cases.
doi:10.4103/0976-3147.145197
PMCID: PMC4271377  PMID: 25540534
Deformity; elimination; subclinical cases
23.  Six months fixed duration multidrug therapy in paucibacillary leprosy: risk of relapse and disability in Agra PB cohort study 
BMJ Open  2012;2(4):e001403.
Background
Many studies have focused on multidrug therapy (MDT) for multibacillary (MB) leprosy and rarely on long-term outcome of paucibacillary (PB) leprosy having recommendation of therapy for 6 months fixed duration therapy for PB patients. Studies on measuring risk of disability are rare. The present study is to assess the cure; default, relapse and disability in a prospective cohort of PB leprosy during follow-up of >4 years after treatment.
Design
Prospective.
Setting
Primary in our field area of Agra District.
Participants
920 PB leprosy patients entered the study, 621 completed treatment, 599 followed finally including 271 males, no ethnic differentiation, patients of all age groups except for children below 5 years and old persons above 70 years were not included.
Treatment
6 months fixed duration MDT as recommended by WHO.
Primary and secondary outcomes
Treatment completion, cure, relapse and development of disability based on clinical assessment by well-experienced doctors.
Statistical methods
Data have been analysed using SPSS software, risk is computed as incidence per 100 person–years (PY) and test of significance used.
Results
Study reports 91% cure rate. Incidence of relapse was 1.3/100 PY with no significant variation by age, sex, delay in detection, patches and nerves. Crude incidence of disability was 2.2% and varied significantly by age and nerve thickening but not by sex, number of patches, nerves and delay in treatment. Incidence of disability was 0.50/100 PY in treatment completed and 0.43 among defaulters.
Conclusion
The study concludes that relapses do occur after MDT treatment but at the level of 1–2%, incidence of disability remains low (<1/100 PY) in PB leprosy. Low incidence of relapse and disability suggests that 6 months therapy is quite effective. However, further improvement may help to improve its efficacy. Longer follow-up may add to efficacy measures.
doi:10.1136/bmjopen-2012-001403
PMCID: PMC3425897  PMID: 22893667
Biotechnology & Bioinformatics; Health informatics; Epidemiology; Dermatology; Dermatological epidemiology; Chemotherapy
24.  Active Surveillance of Hansen's Disease (Leprosy): Importance for Case Finding among Extra-domiciliary Contacts 
Hansen's disease (leprosy) remains an important health problem in Brazil, where 34,894 new cases were diagnosed in 2010, corresponding to 15.3% of the world's new cases detected in that year. The purpose of this study was to use home visits as a tool for surveillance of Hansen's disease in a hyperendemic area in Brazil. A total of 258 residences were visited with 719 individuals examined. Of these, 82 individuals had had a previous history of Hansen's disease, 209 were their household contacts and 428 lived in neighboring residences. Fifteen new Hansen's disease cases were confirmed, yielding a detection rate of 2.0% of people examined. There was no difference in the detection rate between household and neighbor contacts (p = 0.615). The two groups had the same background in relation to education (p = 0.510), household income (p = 0.582), and the number of people living in the residence (p = 0.188). Spatial analysis showed clustering of newly diagnosed cases and association with residential coordinates of previously diagnosed multibacillary cases. Active case finding is an important tool for Hansen's disease control in hyperendemic areas, enabling earlier diagnosis, treatment, decrease in disability from Hansen's disease and potentially less spread of Mycobacterium leprae.
Author Summary
Hansen's Disease, or leprosy, is a disease that despite curative therapy is still a health problem in many areas, particularly in Brazil, which has a high new case detection rate. If symptoms of Hansen's disease are not recognized, delay in diagnosis can result in severe disability. Within the state of Rio Grande do Norte, Brazil, a state that has had a low detection rate, we focused on a municipality which is considered hyperendemic. We visited households of previously diagnosed Hansen's disease cases and two neighboring households. There was no difference in the rate of detection of new cases within case and neighbor households, nor differences with respect to education, household income, or the number of people living in the residence. By mapping these households, we found that proximity to a multibacillary case increased the risk of finding a new case of Hansen's disease. Spatial analysis in areas with Hansen's disease should be a tool for implementation of active surveillance to help reduce disease transmission. In addition, it is essential to raise awareness in communities at highest risk to promote early detection and treatment of new cases.
doi:10.1371/journal.pntd.0002093
PMCID: PMC3597486  PMID: 23516645
25.  Postelimination Status of Childhood Leprosy: Report from a Tertiary-Care Hospital in South India 
BioMed Research International  2013;2013:328673.
Introduction. Leprosy, a statistically “eliminated” disease from the globe, continues to linger around in its endemic countries including India. Objective. This study describes the epidemiological and clinicopathological pattern of the disease seen in children over a period of 8 years following its elimination in India. Materials and Methods. Medical records of all leprosy cases up to 14 years of age registered between April 2005 and March 2013 were retrospectively analyzed. Data were retrieved using a predesigned proforma and entered into the database system for analysis. Results. Child proportion of newly registered leprosy cases did not show a significant decline in the years following its elimination. The disease seemed to manifest frequently in older children with an insignificant gender predilection. More than half of child cases had a history of household contact. Paucibacillary leprosy dominated in them with a solitary skin lesion as the most frequent presentation. Although nerve thickening was seen in nearly half of these children, neuritis and lepra reactions were less common. Deformity at the time of diagnosis was noted in 13.89% of cases. Although smear positivity was not a common feature in children affected with leprosy, a good clinicohistopathological correlation was observed in those who underwent biopsy. Conclusion. Our study and reports from different parts of the country depict the unturned curves in the epidemiology of childhood leprosy which mirrors active transmission in the community, lacunae in diagnosis, and the need to strengthen contact screening activities in the pediatric population to sustain elimination.
doi:10.1155/2013/328673
PMCID: PMC3780613  PMID: 24089672

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