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1.  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
2.  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
3.  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
4.  Current Knowledge Attitudes, and Practices of Healthcare Providers about Leprosy in Assam, India 
Background:
Leprosy is a chronic infectious disease that is associated with serious morbidity and is a disease of public health concern because of the case load and the social stigma attached to the disease.
Aim:
To understand the knowledge of, and attitudes towards, leprosy amongst healthcare providers in Assam, India.
Settings and Design:
This cross-sectional study was conducted during March to June 2007 in different health institutions of the Kamrup district of Assam.
Results:
Among the program managers interviewed, only half were organizing training sessions, and 37.5% were involved in supervision of the program activities at the periphery level. Among the program managers who were involved with leprosy elimination, only half were organizing training session and 37.5% were involved in supervision of the program activities at the periphery level. Medical officers consistently demonstrated higher knowledge about leprosy, followed by health supervisors and multipurpose workers (MPWs), including nursing staff. Regarding training status with regard to leprosy, 90% of medical officers, 80% of health supervisors and around 87% of MPWs (83% of male MPWs and 89% of female MPWs) had attended training programs on leprosy. Regarding WHO MDT, 80% of health supervisors, 84.8% of male MPWs and 86.2% of female MPWs had an idea of MDT and treatment duration of various categories of patients.
Conclusions:
These observations suggest that there appear to be adequate knowledge and positive behavior among healthcare providers with regard to leprosy in this part of India. However, there is still a need to organize training programs at regular intervals to train new recruits, as well as reinforce and update the knowledge of those already trained.
doi:10.4103/0974-777X.68527
PMCID: PMC2946674  PMID: 20927279
Attitudes; Behavior; Healthcare providers; Leprosy
5.  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
6.  New Biomarkers with Relevance to Leprosy Diagnosis Applicable in Areas Hyperendemic for Leprosy1 
Leprosy is not eradicable with currently available diagnostics or interventions as evidenced by its stable incidence. Early diagnosis of Mycobacterium leprae infection should therefore be emphasized in leprosy-research. It remains challenging to develop tests based on immunological biomarkers that distinguish individuals controlling bacterial replication from those developing disease.
To identify biomarkers for field-applicable diagnostics, we determined cytokines/chemokines induced by M. leprae proteins in blood of leprosy patients and controls (EC) from high leprosy-prevalence areas (Bangladesh, Brazil, Ethiopia) and from South Korea where leprosy is not endemic anymore.
M. leprae- sonicate induced IFN-γ was similar for all groups, excluding M. leprae/IFN-γ as a diagnostic read-out. By contrast, ML2478 and ML0840 induced high IFN-γ concentrations in Bangladeshi EC, which were completely absent for South Korean controls. Importantly, ML2478/IFN-γ could indicate distinct degrees of M. leprae exposure, and thereby the risk of infection and transmission, in different parts of Brazilian and Ethiopian cities.
Notwithstanding these discriminatory responses, M. leprae proteins did not distinguish patients from EC in one leprosy endemic area based on IFN-γ. Analyses of additional cytokines/chemokines showed that M. leprae and ML2478 induced significantly higher concentrations of MCP-1, MIP-1β and IL-1β in patients compared to EC, whereas IP-10, like IFN-γ, differed between EC from areas with dissimilar leprosy prevalence.
This study identifies M. leprae-unique antigens, particularly ML2478, as biomarker tools to measure M. leprae exposure using IFN-γ or IP-10, and also shows that MCP-1, MIP-1β and IL-1β can potentially distinguish pathogenic immune responses from those induced during asymptomatic exposure to M. leprae.
doi:10.4049/jimmunol.1103452
PMCID: PMC3345093  PMID: 22504648
Mycobacterium leprae (M. leprae); biomarkers; leprosy; multiplex analysis
7.  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
8.  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
9.  Leprosy in Post-Elimination Era in India: Difficult Journey Ahead 
Indian Journal of Dermatology  2013;58(6):443-446.
Leprosy is a chronic inflammatory disease of skin and peripheral nerves. Elimination of leprosy as a public health problem was reached at the global level in the year 2000 and by India on 31st December, 2005. Thereafter, leprosy services in India have been integrated with General Health-Care System resulting in reduced focus and funds. Sustaining the gains made so far in controlling leprosy is a big challenge and there is no time for complacency. Pockets of high endemicity with prevalence rate of > 1 still exist in many states. Our data from a tertiary care center indicates poor epidemiological control and ongoing disease transmission. To combat this, dermatologists all over India should continue to play a central role in capacity building and training of undergraduate and post-graduate students, medical officers, and field workers.
doi:10.4103/0019-5154.119952
PMCID: PMC3827515  PMID: 24249895
Elimination; epidemiological indicators; leprosy; prevalence rate
10.  Leprosy: a primer for Canadian physicians 
LEPROSY IS A RARE BUT SERIOUS INFECTIOUS DISEASE caused by Mycobacterium leprae. While global prevalence of the disease is decreasing, increasing rates of immigration from countries where leprosy is endemic have led to the recognition of this illness in North America. Classically, leprosy presents as hypopigmented cutaneous macules along with sensory and motor peripheral neuropathies, although the clinical manifestations vary along a disease spectrum. In addition to primary infection, patients may undergo a “reaction,” an acute inflammatory response to the mycobacterium, which leads to pain and erythema of skin lesions and dangerous neuritis. Reactions can occur at any time during the course of leprosy, but they tend to be precipitated by treatment. They are a significant cause of impaired quality of life due to marked nerve damage and thus warrant prompt intervention. Although leprosy may have a protracted onset and be difficult to recognize, cure is achievable with appropriate multidrug therapy. Because untreated leprosy can result in permanent, irreversible nerve damage and secondary transmission, early diagnosis and treatment are essential to minimize morbidity.
PMCID: PMC305320  PMID: 14707226
11.  Ocular Complications of Leprosy in Yemen 
Objectives:
This study was conducted to identify the main ocular- and vision-threatening complications of leprosy in Yemen.
Methods:
This is a cross-sectional observational study which took place from February to July 2010. Leprosy patients attending the Skin and Venereal Diseases Hospital in the City of Light in Taiz, Yemen, who consented to participate in the study, were enrolled. Detailed demographic and medical histories were taken and clinical examination findings were recorded. A detailed eye examination, including visual acuity (VA), slit-lamp, and fundus examinations, was conducted on each patient by a qualified ophthalmologist.
Results:
A total of 192 patients (180 male, 12 female, with a male to female ratio of 15:1) were included in the study. The majority of the patients (157; 81.8%) were over 40 years. Over two-thirds of the patients (129; 67.2%) had had leprosy for more than 20 years. Ocular complications were found in 97% of cases; 150 (39.1%) of the patients’ eyes had at least one pathology. Eyelid involvement was the most common problem observed in 102 (26.5%) patients. Half of the eyes (192; 50%) had a VA of <6/60. The main cause of blindness among these patients was corneal opacity detected in 69 out of 192 patients (35.9%).
Conclusion:
Ocular complications are frequent among leprosy patients in Yemen. They are true vision-threatening lesions. It is important to prevent these lesions through early diagnosis and adequate treatment.
PMCID: PMC3523995  PMID: 23275842
Leprosy; Blindness; Corneal opacity; Eyelid; Yemen
12.  Community care of the physically disabled due to leprosy 
This preliminary presentation based on extensive field studies carried out by Bombay Leprosy Project, a research-oriented NGO, portrays the alarming dimensions of the disease burden felt by rural communities and recommends a cost effective field model. This study in an adopted rural population in Shahapur “taluka” of Thane District assumes tremendous significance and is worthy of replication in comparable situations. This is particularly so in the background of the absence in the literature of any similar field studies based entirely on community care of the physically disabled due to leprosy. The magnitude of the problem posed by leprosy patients with disabilities and their rehabilitation is highly challenging and is expected to pose a heavy burden on the community as well as unprecedented strain on the PHCs managed by the government. The health planners should rethink on future strategies in such a manner that human rights of the downtrodden patients suffering from the “neglected disease” of leprosy are not sidelined
doi:10.4103/2229-5178.85994
PMCID: PMC3481824  PMID: 23130228
Community; door step services; leprosy disabilities
13.  An Orthopedic-, Surgical-, and Epidemiological-Based Investigation of Leprosy, in the Tamil Nadu State of India 
Advances in Orthopedics  2012;2012:783853.
No other research paper has ever been written about leprosy in this manner. The orthopedic and surgical implications, as well as the functional debility caused by the disease, have not been previously explained by past research as they have in such a comprehensive manner in this paper. The results of this study have regional and global implications as they pertain to disease pathology, risk factor recognition/disease prevention, and treatment. This paper is a unique, in that it also serves as a combination of a review of the current medical literature, as well as an epidemiological survey of the disease in a region of the world which has never been researched in the past. Clinical data points to the possibility of a new strain of the disease. This information is of significance because it effects prevention and improved treatment of the disease, which leads to devastating sequela. This was a cross-sectional study involving subjects diagnosed with leprosy in the Chengalpet region of the Kancheepuram District, of the Tamil Nadu state of India. The study was performed at the Tamil Nadu Medical College Teaching Hospital and Research Center. This study included various physical examinations, observation and survey of lesions, questionnaires in regard the debilitating orthopedic and medical effects of the disease, as well as treatment options.
doi:10.1155/2012/783853
PMCID: PMC3362809  PMID: 22666605
14.  The Leprosy Agents Mycobacterium lepromatosis and Mycobacterium leprae in Mexico 
Summary
Background
Mycobacterium leprae was the only known cause of leprosy until 2008, when a new species, named Mycobacterium lepromatosis, was found to cause diffuse lepromatous leprosy (DLL), a unique form of leprosy endemic in Mexico.
Methods
We sought to differentiate the leprosy agents among 120 Mexican patients with various clinical forms of leprosy and to compare their relative prevalence and disease features. Archived skin biopsy specimens from these patients were tested for both M. leprae and M. lepromatosis using polymerase chain reaction-based species-specific assays.
Results
Eighty-seven (72.5%) patients were confirmed for etiologic species, including 55 with M. lepromatosis, 18 with M. leprae, and 14 with both organisms. The endemic regions of each agent differed but overlapped. Patients with M. lepromatosis were younger and from more states, and their clinical diagnoses included 13 DLL, 34 lepromatous leprosy (LL), and eight other forms of leprosy. By contrast, the diagnoses of patients with M. leprae included none DLL, 15 LL and three other forms. Thus, M. lepromatosis caused DLL specifically (p=0.023). Patients with M. lepromatosis also showed more variable skin lesions and the extremities were the commonest biopsy sites. Finally, patients with dual infections manifested all clinical forms and accounted for 16.1% of all species-confirmed cases.
Conclusions
M. lepromatosis is another cause of leprosy and is probably more prevalent than M. leprae in Mexico. It mainly causes LL and also specifically DLL. Dual infections caused by both species may occur in endemic area.
doi:10.1111/j.1365-4632.2011.05414.x
PMCID: PMC3397401  PMID: 22788812
leprosy; diffuse lepromatous leprosy; Lucio’s phenomenon; Mycobacterium lepromatosis; Mycobacterium leprae
15.  Health-related quality of life, depression, and self-esteem in adolescents with leprosy-affected parents: results of a cross-sectional study in Nepal 
BMC Public Health  2013;13:22.
Background
Leprosy is a chronic infectious disease that has an impact on the Health-Related Quality of Life (HRQOL) of sufferers as well as their children. To date, no study has investigated the effects of parental leprosy on the well-being of adolescent children.
Methods
A cross-sectional study was conducted in the Lalitpur and Kathmandu districts of Nepal. Adolescents with leprosy-affected parents (n = 102; aged 11–17 years) and those with parents unaffected by leprosy (n = 115; 11–17 years) were investigated. Self-reported data from adolescents were collected using the Kinder Lebensqualität Fragebogen (KINDLR) questionnaire to assess HRQOL, the Center for Epidemiological Studies-Depression Scale (CES-D), and the Rosenberg Self-esteem Scale (RSES). Analysis of covariance (ANCOVA) was used to compare scores between the two groups. Multiple regression analysis was conducted to explore the determinants of HRQOL for adolescents with leprosy-affected parents.
Results
ANCOVA revealed that the KINDLR and RSES scores were significantly lower among adolescents with leprosy-affected parents compared with unaffected parents. However, the scores of “Friends” and “School” subscales of KINDLR were similar between the two groups. The CES-D score was significantly higher among adolescents with leprosy-affected parents than for adolescents with unaffected parents. The KINDLR scores for adolescents with both parents affected (n = 41) were significantly lower than the scores for those with one parent affected (n = 61). Multiple regression analysis revealed that adolescents with leprosy-affected parents who had higher levels of depressive symptoms were more likely to have lower KINDLR scores. A similar result was seen for adolescents where both parents had leprosy.
Conclusions
Adolescents with leprosy-affected parents had higher levels of depressive symptoms, lower levels of self-esteem, and lower HRQOL compared with adolescents whose parents were unaffected by leprosy. Thus, mental health support programs might be necessary for adolescents with leprosy-affected parents, particularly for adolescents where both parents are leprosy-affected. Further studies with larger sample sizes are necessary to draw decisive conclusions.
doi:10.1186/1471-2458-13-22
PMCID: PMC3544731  PMID: 23305620
Adolescents; Leprosy-affected parents; Quality of life; Mental health; Nepal
16.  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
17.  Use of Short Tandem Repeat Sequences to Study Mycobacterium leprae in Leprosy Patients in Malawi and India 
Background
Inadequate understanding of the transmission of Mycobacterium leprae makes it difficult to predict the impact of leprosy control interventions. Genotypic tests that allow tracking of individual bacterial strains would strengthen epidemiological studies and contribute to our understanding of the disease.
Methodology/Principal Findings
Genotyping assays based on variation in the copy number of short tandem repeat sequences were applied to biopsies collected in population-based epidemiological studies of leprosy in northern Malawi, and from members of multi-case households in Hyderabad, India. In the Malawi series, considerable genotypic variability was observed between patients, and also within patients, when isolates were collected at different times or from different tissues. Less within-patient variability was observed when isolates were collected from similar tissues at the same time. Less genotypic variability was noted amongst the closely related Indian patients than in the Malawi series.
Conclusions/Significance
Lineages of M. leprae undergo changes in their pattern of short tandem repeat sequences over time. Genetic divergence is particularly likely between bacilli inhabiting different (e.g., skin and nerve) tissues. Such variability makes short tandem repeat sequences unsuitable as a general tool for population-based strain typing of M. leprae, or for distinguishing relapse from reinfection. Careful use of these markers may provide insights into the development of disease within individuals and for tracking of short transmission chains.
Author Summary
Molecular typing has provided an important tool for studies of many pathogens. Such methods could be particularly useful in studies of leprosy, given the many outstanding questions about the pathogenesis and epidemiology of this disease. The approach is particularly difficult with leprosy, however, because of the genetic homogeneity of M. leprae and our inability to culture it. This paper describes molecular epidemiological studies carried out on leprosy patients in Malawi and in India, using short tandem repeat sequences (STRS) as markers of M. leprae strains. It reveals evidence for continuous changes in these markers within individual patients over time, and for selection of different STRS-defined strains between different tissues (skin and nerve) in the same patient. Comparisons between patients collected under different circumstances reveal the uses and limitations of the approach—STRS analysis may in some circumstances provide a means to trace short transmission chains, but it does not provide a robust tool for distinguishing between relapse and reinfection. This encourages further work to identify genetic markers with different stability characteristics for incorporation into epidemiological studies of leprosy.
doi:10.1371/journal.pntd.0000214
PMCID: PMC2271132  PMID: 18398487
18.  Trophic Skin Ulceration of Leprosy: Skin and Serum Zinc Concentrations 
British Medical Journal  1974;2(5918):531-533.
Skin and serum zinc measurements have been made in patients with leprosy with and without trophic skin ulceration and in several other groups. Serum zinc concentrations were decreased in leprosy irrespective of the presence or absence of skin ulceration. Serum zinc concentrations in leprosy were also unrelated to smears positive for Mycobacterium leprae and to the clinical type of leprosy. Since a decrease of the serum zinc was also found in patients with dermatitis herpetiformis and pulmonary tuberculosis it seems likely that the decreased serum zinc in leprosy is a nonspecific metabolic consequence of chronic skin and internal disease. The mean skin zinc concentration in leprosy did not differ significantly from the corresponding value in control subjects, the lack of agreement between serum and skin concentrations being possibly related to the presence of nonexchangeable keratin-bound zinc in skin. Though the clinical significance of lowered serum zinc concentrations in leprosy is uncertain therapeutic trials of zinc treatment in leprosy with trophic skin ulceration seem justifiable.
PMCID: PMC1610909  PMID: 4601207
19.  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
20.  Leprosy 
Clinical Evidence  2010;2010:0915.
Introduction
The World Health Organization field leprosy classification is based on the number of skin lesions: paucibacillary leprosy (1–5 skin lesions), and multibacillary leprosy (more than 5 skin lesions). Worldwide, about 250,000 new cases of leprosy are reported each year, and about 2 million people have leprosy-related disabilities.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent leprosy? What are the effects of treatments for leprosy? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 20 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: chemoprophylaxis with single-dose rifampicin, Bacillus Calmette–Guerin (BCG) plus killed Mycobacterium leprae vaccine, BCG vaccine, ICRC vaccine, multidrug treatment, multiple-dose treatment, Mycobacterium w vaccine, and single-dose treatment.
Key Points
Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae, primarily affecting the peripheral nerves and skin. The WHO field leprosy classification is based on the number of skin lesions: paucibacillary leprosy (1–5 skin lesions), and multibacillary leprosy (more than 5 skin lesions).Worldwide, about 250,000 new cases of leprosy are reported each year, and about 2 million people have leprosy-related disabilities.
Chemoprophylaxis given to contacts of index cases is moderately effective in preventing leprosy. Chemoprophylaxis with single-dose rifampicin reduces the incidence of leprosy in contacts of new cases, although the effect is only seen in the first 2 years.
Vaccination is the most efficient method of preventing the contraction of leprosy. Vaccination with Bacillus Calmette–Guerin (BCG) vaccine, either alone or in combination with killed M leprae , reduces the incidence of leprosy. BCG and BCG plus killed M leprae seem to be as effective as each other at reducing the incidence of leprosy. ICRC vaccine prevents leprosy and produces few adverse effects, although its formulation is unclear and we only found evidence in one geographical area. Mycobacterium w vaccine reduces the incidence of leprosy compared with placebo.
Leprosy is generally treated with multidrug programmes. Despite sparse good RCT or cohort study evidence, there is consensus that multidrug treatment (rifampicin plus clofazimine plus dapsone) is highly effective for treating multibacillary leprosy. Placebo-controlled trials of multidrug treatment would now be considered unethical. Multidrug treatment with rifampicin plus dapsone is believed to improve skin lesions, nerve impairment, and relapse rates in people with paucibacillary leprosy, despite a lack of good evidence. Multiple-dose treatments with rifampicin monthly plus dapsone daily for 6 months are more effective than single-dose treatments with rifampicin plus minocycline plus ofloxacin for treating people with single skin lesions (although both achieve high cure rates).
PMCID: PMC3217821  PMID: 21418690
21.  Leprosy: An Overview of Pathophysiology 
Leprosy, also known as Hansen's disease, is a chronic infectious disease caused by Mycobacterium leprae, a microorganism that has a predilection for the skin and nerves. The disease is clinically characterized by one or more of the three cardinal signs: hypopigmented or erythematous skin patches with definite loss of sensation, thickened peripheral nerves, and acid-fast bacilli detected on skin smears or biopsy material. M. leprae primarily infects Schwann cells in the peripheral nerves leading to nerve damage and the development of disabilities. Despite reduced prevalence of M. leprae infection in the endemic countries following implementation of multidrug therapy (MDT) program by WHO to treat leprosy, new case detection rates are still high-indicating active transmission. The susceptibility to the mycobacteria and the clinical course of the disease are attributed to the host immune response, which heralds the review of immunopathology of this complex disease.
doi:10.1155/2012/181089
PMCID: PMC3440852  PMID: 22988457
22.  Indeterminate leprosy and lepromatous index case: four cases in the same family*  
Anais Brasileiros de Dermatologia  2013;88(6 Suppl 1):105-108.
Leprosy is a chronic infectious disease caused by Mycobacterium leprae, which primarily affects the skin and peripheral nerves. Brazil remains as the country with the second largest number of cases in the world. We report the case of three patients diagnosed with indeterminate leprosy in the same family. Two patients were HIV positive. An active search led to the discovery of the index case. It was crucial to persist in the search of the index case. This report shows how important it is to teach physicians and the general population about the signs and symptoms of leprosy. Early diagnosis and treatment are necessary to prevent sequelae and to eliminate the disease as a public health problem.
doi:10.1590/abd1806-4841.20132050
PMCID: PMC3875986  PMID: 24346893
HIV; Leprosy; Leprosy, lepromatous; Leprosy, paucibacillary
23.  Progression of leprosy neuropathy: a case series study 
Brain and Behavior  2012;2(3):249-255.
A need still exists to determine the clinical and neurophysiological characteristics of leprosy neuropathy at distinct times of the disease by different methods that measure the various nerve fiber functions. A prospective clinical study was performed with 10 paucibacillary (PB) and 12 multibacillary (MB) patients evaluated at diagnosis and one year after cessation of multidrug therapy (MDT). Peripheral nerve function was assessed clinically and by means of the sympathetic skin response, skin vasomotor reflex, and nerve conduction study (NCS). At diagnosis, 73% of the total 22 patients had nerve function impairment (NFI). Autonomic function (χ2= 5.5, P= 0.019) and NCS (χ2= 7.765, P= 0.01) were significantly more altered in MB than PB patients. At final evaluation, NFI of the MB patients had worsened, especially among the six who had leprosy reaction. As the NFI of PB patients showed improvement, a significant difference between the two groups (χ2= 12.320, P= 0.001) was observed. A high prevalence of neuropathy was observed in newly diagnosed patients. Associating different tests with a thorough clinical neurological evaluation increases detection rates.
doi:10.1002/brb3.40
PMCID: PMC3381630  PMID: 22741099
Leprosy; nerve conduction study; peripheral neuropathy; skin vasomotor reflex; sympathetic skin response
24.  Fixed-Duration Therapy in Leprosy: Limitations and Opportunities 
Indian Journal of Dermatology  2013;58(2):93-100.
Leprosy has been considered a curable disease after the implementation of multidrug therapy (MDT), which has been proven to be safe and effective, by bringing about a significant change in the global and national scenario of leprosy by upgrading the control of leprosy to the next stage of eradication. Since its introduction, the MDT regimens for the treatment of leprosy have undergone several changes especially with regard to the duration of treatment. The advantages of shortened duration of treatment need to be balanced against the risk of relapse and a lot of controversies exist pertaining to this aspect. The fixed-duration (FD) therapy is not popular among academicians and private practitioners who prefer precise diagnosis and treatment with superior MDT regimens and for a longer duration. On the contrary, from a public health-care point of view, precise diagnosis and a longer treatment schedule are not cost effective and not feasible to be implemented in elimination programs. Hence, a fine balance needs to be maintained between achieving a cure for the patient and protecting the society at risk, and this review discusses the various limitations and opportunities of FD therapy with a note on the newer MDT regimens.
doi:10.4103/0019-5154.108029
PMCID: PMC3657276  PMID: 23716796
Fixed duration; leprosy; multibacillary; multidrug therapy; paucibacillary
25.  Identification and Distribution of Mycobacterium leprae Genotypes in a Region of High Leprosy Prevalence in China: a 3-Year Molecular Epidemiological Study▿  
Journal of Clinical Microbiology  2007;45(6):1728-1734.
Multiple-locus variable-number tandem-repeat (VNTR) analysis (MLVA) has been proposed as a means of strain typing for tracking the transmission of leprosy. However, empirical data for a defined population are lacking. To this end, a study was initiated to assess the diversity and distribution of prevalent Mycobacterium leprae strains in Qiubei County, Yunnan Province, People's Republic of China, where the annual detection rate of leprosy is 10-fold higher than the national average rate. Sixty-eight newly diagnosed leprosy patients were included in the study. MLVA at eight M. leprae loci was applied using DNA extracts from skin biopsies. The number of alleles per locus ranged from 4 to 24, providing adequate strain discrimination. MLVA strain typing identified several clusters of patients whose M. leprae specimens shared similar VNTR profiles. Two of these clusters were comprised of patients who resided predominantly in the north and northwest parts of Qiubei County. Furthermore, it was found that multicase families are common in this county: 23 of the 68 patients were from 11 families. Intrafamilial VNTR profiles closely matched within six families, although they were different between the families. Moreover, VNTR patterns related to those found in some multicase families were also detected in patients in the same or adjacent townships, indicating the utility of VNTR strain typing to identify and detect short-range transmission events. Social contact through village markets is proposed as a means of transmission.
doi:10.1128/JCM.00018-07
PMCID: PMC1933063  PMID: 17428944

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