Progression of leprosy disability after discharge: is multidrug therapy enough?

Potentially disabling factors of newly diagnosed leprosy patients in southwest China: a retrospective observational study

BACKGROUND

With the prevalence of leprosy dramatically declining, the focus of leprosy control has gradually shifted from the implementation of multidrug therapy (MDT) to accelerating the reduction of the disease burden and preventing disability. Southwestern China currently bears the highest leprosy burden in China and more than half of the disability cases reported every year are from this region. However, the potential risk factors of leprosy disability in this area remain unknown.

METHODS

In this study, we evaluated the physical disabilities of 4578 leprosy patients in southwest China from 2010 to 2020. Clinical and epidemiological factors associated with physical disability resulting from leprosy were identified using multinomial logistic regression.

RESULTS

A total of 4578 leprosy cases with complete information were reported in southwestern China during the 11 years. Among them, 1126 (24.60%) patients were diagnosed with grade 2 disability (G2D), and 737 (16.10%) were confirmed with grade 1 disability (G1D) at diagnosis. The potential factors associated with G2D are as follows: nerve damage, male, leprosy reaction, older age of the patient, the longer delay in diagnosis, and more skin lesions. Furthermore, nerve damage, leprosy reaction, male, older age, and longer delayed diagnosis were the main risk factors of G1D. Among them, nerve damage, older age, longer delayed diagnosis, male, and leprosy reaction were the common risk factors for G1D and G2D.

CONCLUSION

In our study, we found older age, longer delayed diagnosis, male, more skin lesions, more nerve lesions, and leprosy reactions were associated with leprosy disability. These findings provide a foundation for the development of targeted interventions aimed at the early identification of individuals at higher risk of physical disability, as well as for self-care and health education to promote timely medical consultation to prevent leprosy-related disabilities.

Relevance of reporting leprosy related disability at the completion of multi drug therapy: A 5-year retrospective analysis of disability in persons affected by leprosy at ALERT Hospital Ethiopia

BACKGROUND

Leprosy is one of the neglected tropical diseases associated with significant morbidity in endemic regions. It causes disability affecting the daily activities and social participation of affected individuals. Understanding the prevalence and trend of leprosy-related disability throughout the world and the accuracy of disability data counted by WHO is crucial in guiding efforts to be made towards the targets set by WHO to be achieved by 2030. This study aims to show the significance of reporting leprosy-related disability at the end of MDT and critique how disability is counted in the context of WHO data.

METHODS

This is a mixed method study with a 5-year retrospective analysis of outcomes of newly diagnosed leprosy patients at ALERT Hospital in Ethiopia from 2016 to 2020. A comparative review and analysis of leprosy related G2D (Grade 2 Disability), globally, regionally, and in Ethiopia using WHO data was also done. In addition, semi-structured interview of health workers (HCWs) and professionals working in the field of leprosy at various organizations was conducted.

RESULTS

The trend of G2D among newly diagnosed leprosy patients shows no decline globally for the past 20 years. It is increasing in Africa and stable in the Southeast Asian and American regions where majority of leprosy patients are found showing the gap in early case identification and prompt treatment of leprosy cases. The total number of newly diagnosed leprosy cases at ALERT hospital between January 2016 and December 2020 were 1032 and among those patients who had completed treatment the prevalence of G2D was 33% at diagnosis and 23% at completion. The interview has also shown gaps in the completeness and quality of disability data reported to WHO and how disability is counted.

CONCLUSION

Leprosy related G2D among newly diagnosed patient is not declining worldwide and even increasing in endemic regions like Ethiopia. More training should be given to health professionals in assessing disability. WHO should make some changes in the way it counts disability as the current definitions are prone to interpretation bias and lacks uniformity among various programmes and health workers. Prospective studies are needed in assessing disability progression post MDT so as design interventions and strategies in preventing worsening of disability after patients are discharged from treatment centre.

The marks of leprosy: disabilities caused by plantar lesions in discharged patients

Leprosy is a chronic infectious disease that has a slow evolution and is characterized by dermatoneurological involvement. The health challenges surrounding this disease are closely related to the stigma that results from the physical disabilities it causes. This is due to its high rate of late diagnosis and the peculiar deformities that occur in its advanced stage. Evaluate the clinical and epidemiological aspects of patients with plantar lesions who were treated for leprosy in a dermatology referral unit. This is a cross-sectional exploratory field study that was conducted at the Reference Center in Tropical Dermatology and Venereology Alfredo da Matta (FUHAM), in Manaus, Amazonas, Brazil. We evaluated 36 patients with disabilities as a result of leprosy and who had plantar lesions. The most common ulcer site was the medial region of the plantar surface, which presented dryness and maceration with yellowish seropurulent exudate, fibrinous tissue and grade 2 depth. The study made it possible to observe the evolution of plantar ulcers resulting from the disease process, then evaluate them and discuss recommendations regarding the treatment and prevention of this type of physical disability.

Critical observation of WHO recommended multidrug therapy on the disease leprosy through mathematical study

Leprosy is a skin disease and it is characterized by a disorder of the peripheral nervous system which occurs due to the infection of Schwann cells. In this research article, we have formulated a four-dimensional ODE-based mathematical model which consists of the densities of healthy Schwann cells, infected Schwann cells, M. leprae bacteria, and the concentration of multidrug therapy (MDT). This work primarily aims on exploring the dynamical changes and interrelations of the system cell populations during the disease progression. Also, evaluating a critical value of the drug efficacy rate of MDT remains our key focus in this article so that a safe drug dose regimen for leprosy can be framed more effectively and realistically. We have examined the stability scenario of different equilibria and the occurrence of Hopf-bifurcation for the densities of our system cell populations with respect to the drug efficacy rate of MDT to gain insight on the precise impact of the efficiency rate on both the infected Schwann cell and the bacterial populations. Also, a necessary transversality condition for the occurrence of the bifurcation has been established. Our analytical and numerical investigations in this research work precisely explores that the process of demyelination, nerve regeneration, and infection of the healthy Schwann cells are the three most crucial factors in the leprosy pathogenesis and to control the M. leprae-induced infection of Schwann cells successfully, a more flexible version of MDT regime with efficacy rate varying in the range η∈(0.025,0.059) for 100-120 days in PB cases and 300 days in MB cases obtained in this research article should be applied. All of our analytical outcomes have been verified through numerical simulations and compared with some existing clinical findings.

Risk Factors for Disability Upgrading Among Leprosy Patients During Treatment: Multilevel Modeling Analysis

Background

Leprosy not only brings about bodily incapacity but also creates a nasty image of affected individuals, triggering discrimination and social stigma. The purpose of this study was to evaluate the status of leprosy disability in patients registered at the All African TB and Leprosy Rehabilitation and Training Center.

Methods

The study consists of 205 leprosy patients who were undergoing treatment at the All African TB and Leprosy Rehabilitation and Training Center from January 2015 to December 2019. Regional states of the patients were used as a clustering effect in the multilevel logistic regression model.

Results

In total, 205 (66.3%) completed records revealed patients with leprosy were disabled. Among these, 64.88% of them were males. In multilevel binary logistic regression analysis, the individual-level variables, such as median age (AOR = 1.1; 95% CI: 1.043, 1.13) of patients, patients with duration of symptom [7-12 months (AOR = 2.26; 95% CI: 1.50, 3.39), 13-24 months (AOR = 2.13; 95% CI: 1.44, 3.15), and more than 24 months (AOR = 2.67; 95% CI: 1.8, 4.02)], the absence of sensory loss (AOR = 0.84; 95% CI: 0.72, 0.96), and patients with asymmetry lesion distribution (AOR = 0.74; 95% CI: 0.65, 0.85), were the most significant determinant factors of disability. The default leprosy patient (AOR = 15.53; 95% CI: 1.82, 134.96) and new leprosy patient (AOR = 0.51; 95% CI: 0.33, 1.68) were the significant determinant factors of disability due to leprosy patients.

Conclusion

An individual-level factor on the risk of disability was higher as age increased and for patients with a longer duration of symptoms. The risk of disability was lower for patients who do not lose their sensation and for patients whose lesion distribution is asymmetrical. The community-level factor, patient categories, was also a significant factor in disability due to leprosy. Furthermore, programs should emphasize raising community awareness, focusing on key messages and early case detection campaigns, such as active surveys, as well as the availability of leprosy care in a public health facility.

Experiences of living with leprosy: A systematic review and qualitative evidence synthesis

OBJECTIVE

The objective of the review was to identify, appraise, and synthesise qualitative studies on the lived experience of individuals diagnosed with leprosy, the impact of the disease, and how they coped with the disease burden.

INTRODUCTION

Leprosy is a chronic disease with long-term biopsychosocial impact and is a leading cause of preventable disabilities. It traps the individuals with leprosy in a vicious circle of disease, stigma, and poverty. The efforts to reduce stigma and discrimination and improve their quality of life have not kept pace with the success of the multidrug treatment.

INCLUSION CRITERIA

This review considered published literature on the lived experience of individuals diagnosed with leprosy. There were no limitations on gender, background, or country. All qualitative or mixed-methods studies were accepted.

METHODS

The review followed the JBI meta-aggregation approach for qualitative systematic reviews. A structured literature search was undertaken using multiple electronic databases: PubMed, Embase, Web of Science, and CINAHL.

RESULTS

The search identified 723 publications, and there were 446 articles after deduplication. Forty-nine studies met the inclusion criteria. The final 173 findings were synthesised into ten categories and aggregated into four synthesised findings: biophysical impact, social impact, economic impact, and mental and emotional impact. These synthesised findings were consistent across the included studies from a patient's perspective. The way people coped with leprosy depended on their interpretation of the disease and its treatment. It affected their help-seeking behaviour and their adherence to treatment and self-care. The review has identified a multi-domain effect on the affected individuals, which goes beyond the biological and physical effects, looking at the social issues, specific difficulties, emotions, and economic hardships.

CONCLUSIONS

The researchers, health professionals, and policymakers could use the synthesised findings to address the concerns and needs of the leprosy-affected individuals and offer appropriate support to manage their lives.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO Registration number: CRD42021243223.

Systematic Review of Survival Analysis in Leprosy Studies-Including the Following Outcomes: Relapse, Impairment of Nerve Function, Reactions and Physical Disability

Leprosy is a public health problem in South American, African and Oceanian countries. National programs need to be evaluated, and the survival analysis model can aid in the construction of new indicators. The aim of this study was to assess the period of time until the outcomes of interest for patients with or exposed to leprosy by means of survival analysis surveys. This review researched articles using the databases of PubMed, Science Direct, Scopus, Scielo and BVS published in English and Portuguese. Twenty-eight articles from Brazil, India, Bangladesh, the Philippines and Indonesia were included. The Kaplan-Meier method, which derives the log-rank test, and Cox's proportional hazards regression, which obtains the hazard ratio, were applied. The mean follow-up until the following outcomes were: (I) leprosy (2.3 years) in the population who were exposed to it, (II) relapse (5.9 years), (III) clinical manifestations before, during and after treatment-nerve function impairment (5.2 years), leprosy reactions (4.9 years) and physical disability (8.3 years) in the population of patients with leprosy. Therefore, the use of survival analysis will enable the evaluation of national leprosy programs and assist in the decision-making process to face public health problems.

Clinical and radiological evaluation of maxillofacial and otorhinolaryngological manifestations of Hansen's disease

To characterize maxillofacial, otorhinolaryngological and oral manifestations of Hansen's disease (HD), we conducted a cross-sectional study in 21 current patients attending the Unidade Básica de Saúde de Jardim América, Espírito Santo, Brazil and 16 former patients resident at Pedro Fontes Hospital using data from computed tomography imaging, rhinoscopy, and oroscopy. Maxillofacial characteristics were compared with 37 controls. Differences in bone alterations across the three groups were determined mainly by severe resorption/atrophy being more frequent in former HD patients, with severe resorption/atrophy of the anterior alveolar process of maxilla in 50.0% (8/16) of former patients, 28.6% (6/21) of current patients and 10.8% (4/37) of controls and of nasal bones and aperture in 31.3% (5/16) of former patients compared with 0/21 current patients and two controls. There were no substantial differences in otorhinolaryngological and oroscopic findings between the two patient groups. HD patients had more tooth loss than the age-matched control group. Maxillofacial, otorhinolaryngological and oroscopic finding scores were strongly correlated only in current HD patients. Correlation between otorhinolaryngological and maxillofacial scores suggests that protocols for HD patient assessment and follow-up could include otorhinolaryngological evaluation, with radiological imaging where necessary, subject to replication of our findings in a larger study.

[Factors associated with timing of lepra reactions in a cohort from 2008 to 2016 in Rondônia, Amazon Region, Brazil]

The clinical management of leprosy patients poses a specific challenge, namely lepra reactions. This non-concurrent cohort study aimed to analyze the timing of the first lepra reaction during and after polychemotherapy (PCT) and associated factors. A total of 1,621 patients were assessed (PB = 8.9% and MB = 91.1%) from 2008 to 2016, reported to the System of Reaction States in Leprosy (SisReação/RO) database. Reactions occurred predominantly during PCT (997; 61.5%) and less frequently only after PCT (624; 38.5%). Earliness of the reaction after diagnosis was analyzed with Kaplan-Meier survival curves, with comparison between the PB and MB groups using the Mantel-Cox log-rank test. Univariate and multivariate Cox regression models were constructed to identify factors associated with occurrence of lepra reactions (hazard ratio) and the corresponding 95%CI. The multivariate model included variables with p-values < 0.20 in the univariate analysis. PB patients developed reactions earlier than MB patients. Other characteristics were associated with earlier reactions: female gender and negative smear microscopy. In the aggregate period (during and after PCT), PB presented 24% higher risk of lepra reaction than MB patients, and negative smear microscopy increased this risk by 40% compared to positive smear microscopy. During and after PCT, PB presented 1.3 and 1.6 times the risk, respectively, of reactions when compared to MB patients. We thus recommend prioritizing surveillance of lepra reactions during and after PCT as measures to prevent physical disabilities and to improve quality of life for persons with leprosy.

Low risk of relapse and deformity among leprosy patients who completed multi-drug therapy regimen from 2005 to 2010: A cohort study from four districts in South India

Introduction

Relapse of leprosy among patients released from treatment (RFT) is an indicator of the success of anti-leprosy treatment. Due to inadequate follow-up, relapse in leprosy patients after RFT is not systematically documented in India. Relapsed leprosy patients pose a risk in the transmission of leprosy bacilli. We determined the incidence of relapse and deformity among the patients RFT from the leprosy control programme in four districts in South India.

Methods

We conducted two follow-up surveys in 2012 and 2014 among the leprosy patients RFT between 2005 and 2010. We assessed them for any symptoms or signs of relapse, persistence and deformity. We collected slit skin samples (SSS) for smear examination. We calculated overall incidence of relapse and deformity per 1000 person-years (PY) with 95% confidence intervals (CI) and cumulative risk of relapse.

Results

Overall, we identified 69 relapse events, 58 and 11, during the first and second follow-up surveys, respectively. The incidence of relapse was 5.42 per 1000 PY, which declined over the years after RFT. The cumulative risk of relapse was 2.24%. The rate of deformity among the relapsed patients was 30.9%. The overall incidence of deformity was 1.65 per 1000 person years. The duration of M. leprae detection in smears ranged between 2.38 and 7.67 years.

Conclusions

Low relapse and deformity rates in leprosy RFT patients are indicative of treatment effectiveness. However, a higher proportion of detection of deformity among relapsed cases is a cause for concern. Periodic follow-up of RFT patients for up to 3 years to detect relapses early and ensure appropriate treatment will minimize the development of deformity among relapsed patients.

India achieved leprosy elimination (<1 case/10000 population) in 2005. However, it remains a country with a high burden of leprosy (120,334 cases in 2017–18), with an annual detection of more than 10000 new cases, including children, indicating widespread active transmission. In addition to the untreated leprosy cases, even patients who relapse after release from leprosy treatment play a significant role in disease transmission. Early detection and management of leprosy relapse cases will minimize the disease transmission and might prevent leprosy-associated deformity. Leprosy management services are primarily provided by the government healthcare system in India and supported by several major non-governmental charitable organizations. The burden of leprosy relapse in India cannot be measured since there is no provision to follow-up the patients who complete multi-drug treatment (MDT) in the national leprosy program. We report the incidence of leprosy relapse among the patients who completed leprosy treatment from the national leprosy control program in four districts in South India. The report also highlights the effectiveness of MDT in program settings, the lower risk of developing deformity after treatment completion, and the need to incorporate an appropriately designed follow-up strategy.

Risk factors for physical disability in patients with leprosy disease in Yunnan, China: Evidence from a retrospective observational study

BACKGROUND

Leprosy is potentially debilitating. The risk factors related to physical disabilities associated with leprosy disease in Yunnan, China was not clear.

METHODOLOGY/PRINCIPAL FINDINGS

We studied 10644 newly detected leprosy patients from Yunnan, China, from 1990 to 2019. Factors associated with Grade 1 (G1D) and Grade 2 (G2D) physical disabilities or overall physical disabilities (combined G1D and G2D) associated with leprosy were analyzed using multinomial and ordinal logistic regression analyses. The following factors were associated with the development of physical disability in these patients with leprosy: delayed diagnosis [odds ratio (OR): 5.652, 4.399, and 2.275; 95% confidence intervals (CIs): 4.516-7.073, 3.714-5.212, and 2.063-2.509; for ≥ 10, 5-10 y, and 2-5 years, respectively], nerve damage (OR: 3.474 and 2.428; 95% CI: 2.843-4.244, and 1.959-3.008; for 2 and 1 damaged nerves, respectively), WHO classification of PB (OR: 1.759; 95% CI: 1.341-2.307), Ridley-Jopling classification (OR: 1.479, 1.438, 1.522 and 1.239; 95% CI: 1.052-2.079, 1.075-1.923, 1.261-1.838, and 1.072-1.431; for TT, BT, BB, and BL when compared with LL, respectively), advanced age (OR: 1.472 and 2.053; 95% CI: 1.106-1.960 and 1.498-2.814; for 15-59 and over 60 years old, respectively), zero skin lesions (OR: 1.916; 95% CI: 1.522-2.413), leprosy reaction (OR: 1.528; 95% CI: 1.195-1.952), rural occupation (OR: 1.364; 95% CI: 1.128-1.650), Han ethnicity (OR: 1.268; 95% CI: 1.159-1.386), and male sex (OR: 1.128; 95% CI: 1.024-1.243).

CONCLUSIONS

Delayed diagnosis, nerve damage, no skin lesions, WHO and Ridley-Jopling classifications, leprosy reactions, advanced age, rural occupation, Han ethnicity, and male sex were associated with disability in leprosy patients. Identifying risk factors could help to prevent physical disability.

Psychometric assessment of the EMIC Stigma Scale for Brazilians affected by leprosy

Background

The Stigma Scale of the Explanatory Model Interview Catalogue (EMIC-SS) is a useful option to investigate leprosy-related stigma, but its psychometric qualities are unknown in Brazil. This study investigated the factor structure, the convergent and known-groups validity, and the reliability of the EMIC-SS for Brazilians affected by leprosy.

Methodology

The Brazilian Portuguese version of the EMIC-SS was validated in 180 persons affected by leprosy at a Reference Center in Rio de Janeiro. Confirmatory factorial analysis (CFA) and Cronbach alpha were used to assess the EMIC-SS internal consistency. The Construct validity was tested using Spearman Correlation, Kruskal-Wallis, and Mann-Whitney tests comparing with the Participation Scale, Rosenberg Self-esteem Scale, Beck Depression Inventory, and a Sociodemographic Questionnaire. Test-retest reliability was evaluated with intra-class correlation (ICC).

Main findings

CFA confirmed the one- and two-dimensional models of the scale after retaining 12 of the 15 EMIC-SS items. The 12—item EMIC-SS was consistent (α = 0.78) and reproducible (ICC = 0.751, 95% Confidence Interval = 0.657–0.822, p < 0.0001). A significant correlation was observed between the EMIC-SS and the other scales confirming convergent validity. The EMIC-SS and its factors were able to differentiate several hypothesized groups (age, change of occupation, monthly family income, communicating others about the disease, and perception of difficulty to follow treatment) confirming the scale known-groups validity, both in its one and two-dimensional models.

Conclusions/Significance

Our study found support for the construct validity and reliability of the EMIC-SS as a measure of stigma experienced by people affected by leprosy in Brazil. However, future studies are necessary in other samples and populations with stigmatizing conditions to determine the optimal factor structure and to strengthen the indications of the validated scale.

Disability progression among leprosy patients released from treatment: a survival analysis

Background

Leprosy can be cured, but physical disability (PD) as a result of the infection can progress in the post-release from treatment phase. This study evaluated the likelihood of, and factors associated with, the progression of the PD grade post-release from treatment among leprosy patients treated in Cáceres-MT, Brazil in the period 2000 to 2017.

Methods

A retrospective cohort study and survival analysis were performed in the hyperendemic municipality of Cáceres in the state of Mato Grosso. The study population consisted of newly diagnosed leprosy patients released from treatment between January 1, 2000 and December 31, 2017. The main outcome was the progression of the PD grade with regard to probability and time; and the evaluated covariates included clinical, operational and demographic variables. The Cox proportional risk model was used to estimate the risk ratio (Hazard Ratios) of the covariates. Both an univariate and a multivariate analysis were implemented, with 95% confidence intervals.

Results

The mean time for progression of the PD grade was 162 months for PB and 151 months for MB leprosy patients. The survival curve showed that 15 years after the release from treatment, the probability of PD grade progression was 35%, with no difference between PB and MB or age groups. Leprosy reactions and registered medical complaints of any kind during treatment were identified as risk factors with Hazard Ratios of 1.6 and 1.8 respectively.

Conclusions

People released from treatment as cured of leprosy are susceptible to worsening of the PD, especially those who have had complications during multi-drug therapy treatment. This indicates that leprosy patients should be periodically monitored, even after the successful completion of multidrug therapy.

Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study

BACKGROUND

Indirect financial costs and barriers to health-care access might contribute to leprosy treatment non-adherence. We estimated the association of the Brazilian conditional cash transfer programme, the Programa Bolsa Família (PBF), on leprosy treatment adherence and cure in patients in Brazil.

METHODS

In this quasi-experimental study, we linked baseline demographic and socioeconomic information for individuals who entered the 100 Million Brazilian Cohort between Jan 1, 2007, and Dec 31, 2014, with the PBF payroll database and the Information System for Notifiable Diseases, which includes nationwide leprosy registries. Individuals were eligible for inclusion if they had a household member older than 15 years and had not received PBF aid or been diagnosed with leprosy before entering the 100 Million Brazilian Cohort; they were excluded if they were partial receivers of PBF benefits, had missing data, or had a monthly per-capita income greater than BRL200 (US$50). Individuals who were PBF beneficiaries before leprosy diagnosis were matched to those who were not beneficiaries through propensity-score matching (1:1) with replacement on the basis of baseline covariates, including sex, age, race or ethnicity, education, work, income, place of residence, and household characteristics. We used logistic regression to assess the average treatment effect on the treated of receipt of PBF benefits on leprosy treatment adherence (six or more multidrug therapy doses for paucibacillary cases or 12 or more doses for multibacillary cases) and cure in individuals of all ages. We stratified our analysis according to operational disease classification (paucibacillary or multibacillary). We also did a subgroup analysis of paediatric leprosy restricted to children aged up to 15 years.

FINDINGS

We included 11 456 new leprosy cases, of whom 8750 (76·3%) had received PBF before diagnosis and 2706 (23·6%) had not. Overall, 9508 (83·0%) patients adhered to treatment and 10 077 (88·0%) were cured. After propensity score matching, receiving PBF before diagnosis was associated with adherence to treatment (OR 1·22, 95% CI 1·01-1·48) and cure (1·26, 1·01-1·58). PBF receipt did not significantly improve treatment adherence (1·37, 0·98-1·91) or cure (1·12, 0·75-1·67) in patients with paucibacillary leprosy. For patients with multibacillary disease, PBF beneficiaries had better treatment adherence (1·37, 1·08-1·74) and cure (1·43, 1·09-1·90) than non-beneficiaries. In the propensity score-matched analysis in 2654 children younger than 15 years with leprosy, PBF exposure was not associated with leprosy treatment adherence (1·55, 0·89-2·68) or cure (1·57, 0·83-2·97).

INTERPRETATION

Our results suggest that being a beneficiary of the PBF, which facilitates cash transfers and improved access to health care, is associated with greater leprosy multidrug therapy adherence and cure in multibacillary cases. These results are especially relevant for patients with multibacillary disease, who are treated for a longer period and have lower cure rates than those with paucibacillary disease.

FUNDING

CONFAP/ESRC/MRC/BBSRC/CNPq/FAPDF-Doenças Negligenciadas, the UK Medical Research Council, the Wellcome Trust, and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brazil (CAPES).

Causes of Death among Persons Affected by Leprosy in Korea, 2010-2013

In addition to the complications of leprosy, people affected by leprosy (PALs) can suffer from chronic diseases. We evaluated the recent pattern of deaths among Korean PALs and compared it with that in the general population. We analyzed the death certificate data of 1,359 PALs from 2010 through 2013. The all-cause and cause-specific standardized mortality ratio (SMR) and standardized mortality with 95% CI were calculated. Malignancy had the highest standardized mortality, with 130.9 deaths per 100,000 persons, followed by cardiovascular diseases (CVDs; 85.5 deaths) and respiratory diseases (38.2 deaths). Of malignancies, liver cancer caused the greatest number of cancer deaths (40.0 deaths). The all-cause mortality of PALs was significantly lower than that in the general population, corresponding to an SMR of 0.84 (95% CI 0.79-0.88). Deaths from malignancy and CVDs were significantly lower, corresponding to SMRs (95% CIs) of 0.88 (0.79-0.98) and 0.75 (0.67-0.84), respectively. The death rates for lung and stomach cancers were lower, whereas mortality due to liver cancer was higher, with an SMR of 1.79 (95% CI 1.43-2.22). Except for liver cancer and infection, the causes of mortality of PALs tend to be lower than that in the general population. The most common underlying cause of death in PALs was stroke, followed by ischemic heart disease, liver cancer, and pneumonia.

Disabilities in leprosy: an open, retrospective analyses of institutional records

BACKGROUND AND OBJECTIVES

Leprosy remains a leading cause of peripheral neuropathy and disability in the world. Primary objective of the study was to determine the incidence of deformities present at a time of diagnosis and new deformities that patients develop over follow up period.

MATERIAL AND METHODS

An open, retrospective cohort study was performed at a tertiary medical center in western India. Recruitment phase of the study was of 2 years (2009-2010) followed by observation/follow up phase of 7 years till 31st December 2017. New patients with leprosy and released from treatment cases who presented with deformity as defined by WHO disability grade (1998) and subsequently developing new deformities during the follow up period of up to 7 years were included in the study.

RESULTS

The study included 200 leprosy patients. Of the total 254 deformities, 168 (66.14%) deformities were noticed at the moment of diagnosis, 20 (7.87%) deformities occurred during the follow up phase. Of all patients, 21.25% had Grade 1 deformity and 6.31% had Grade 2 or more severe deformity. Deformities of hand were most common in 44.48%, followed by feet 39.76%, and face 15.74% respectively.

LIMITATION OF STUDY

Mode of inclusion of patient was self-reporting during follow up phase so there is possible under reporting of the disabilities.

CONCLUSION

New deformities continue to develop in certain forms of leprosy even after release from treatment. Long-term & regular follow up of patients who have been released from treatment is required.

Assessing the Impact of the Twin Track Socio-Economic Intervention on Reducing Leprosy-Related Stigma in Cirebon District, Indonesia

The consequences of leprosy go beyond the physical, social and psychological, as leprosy can drive persons affected and their families into poverty, stigmatization and disability. This paper describes the impact of a socio-economic development (SED) intervention that uses a twin-track approach (two micro-credit models) to reduce leprosy-related stigma in Cirebon District, Indonesia. A randomized-controlled mixed-methods study design was used to test the effectiveness of the SED intervention. Three scales were used to measure stigma and participation restrictions among 30 SED clients and 57 controls, 20 in-depth interviews with SED clients and seven Focus Group Discussions (FGDs) with key persons were held and 65 profiles of the clients were written up and analysed. The qualitative data shows the socio-economic status of 44 out of 65 SED clients (67%) improved. The median family income increased by 25%, more clients reported higher self-esteem, better interaction with neighbours and less stigma than before, although disclosure concerns remained an issue. The scales indicate a positive effect of the intervention on reducing stigma (e.g., Stigma Assessment and Reduction of Impact (SARI) stigma scale mean difference total score of pre and post assessment for SED clients versus the control group was 8.5 versus 5.6). A twin track socio-economic intervention, if embedded and integrated, can increase participation, and be constructive in reducing leprosy-related stigma.

Grade 2 disabilities in leprosy patients from Brazil: Need for follow-up after completion of multidrug therapy

Background

Leprosy continues to be a public health problem in many countries. Difficulties faced by health services include late diagnosis, under-reporting of new cases, adequate monitoring of disabilities and treatment. Furthermore, systematic follow-up after completion of treatment is important, when new disabilities may occur, or existing disabilities may get worse. The objective of the present study was to determine the prevalence of leprosy-associated grade 2 disabilities (G2D) after completion of multidrug therapy (MDT) and to identify factors associated with G2D.

Methods

We performed a cross-sectional study of 222 leprosy cases registered in Vitória da Conquista, Bahia state, Brazil from 2001–2014. We performed a clinical examination of the study participants and collected socio-economic and clinical information by interview. We identified factors associated with grade 2 disability (G2D) using logis tic regression.

Results

In total, 38 (17.1%) participants were diagnosed with G2D, and 106 (47.7%) with grade 1 disabilities (G1D). The following independent factors were significantly associated with G2D: occurrence of leprosy reaction (adjusted OR = 2.5; 95%CI = 1.09–5.77), thickening and/or tenderness of one or more nerve trunks (adjusted OR = 3.0; CI = 1.13–8.01) and unemployment (adjusted OR = 7.17; CI = 2.44–21.07).

Conclusions

This study shows that physical disabilities remain after completion of MDT and frequently occur in an endemic area in Brazil. Finding new ways to reduce the burden of disability are urgently needed, and may include systematic follow-up of patients after treatment completion combined with evidence-based preventative measures.

Leprosy is a Neglected Tropical Disease that is still common in many countries. Patients who have had leprosy often suffer long-term physical disabilities. For some patients, disabilities occur after finishing treatment or existing disabilities may get worse. We contacted 222 leprosy patients who had previously completed multidrug therapy (MDT) in a typical endemic area in Brazil and assessed leprosy-associated disabilities, and the associated clinical or sociodemographic factors. We found that 17.1% of the participants had severe (grade 2) disabilities. Disabilities were more common among patients who had had a leprosy reaction, thickening and/or tenderness of one or more nerve trunks and were unemployed. The findings are important because we show that physical disabilities occur frequently after treatment completion in this area, and that patients need long-term follow-up by the health system. Integrated measures that consider clinical and socio-economic aspects are also needed to reduce leprosy burden after completion of treatment, such as devising of public policies, implementation of clinical monitoring and the development of evidence-based guidelines for follow-up after release from MDT.

Understanding "patient discharge in leprosy": a concept analysis

OBJECTIVE

To analyze the concept of patient discharge in leprosy.

METHODS

Theoretical study guided in the methodological framework of concept analysis. A bibliographical survey was held from December 2015 to January 2016 using the following bases: SCOPUS, CINAHL, PubMed, LILACS, SCIELO and BDENF, by use of the descriptors "Leprosy" and "Patient Discharge", resulting in 13 studies.

RESULTS

The following were identified as possible uses for the concept: discharge by cure, drug use discharge, bacteriological discharge and post-discharge. The attributes defined were completion of multidrug therapy, completion of multidrug therapy for paucibacillary leprosy, completion of multidrug therapy for multibacillary leprosy and cure from leprosy. The presence of an M. leprae infection, symptoms present in skin and peripheral nerves, diagnosis and treatment and leprosy reactions were identified as antecedents. Consequents were exclusion from the active leprosy record and continuity of health care. One case model and one opposing case were presented.

CONCLUSIONS

The analysis broadened the concept "discharge in leprosy", providing other meanings than the clinical definition of multidrug therapy.

Tendências e padrões espaço-temporais da mortalidade relacionada à hanseníase no Estado da Bahia, Nordeste do Brasil, 1999-2014

Resumo Introdução A hanseníase é uma condição negligenciada, com alta carga de morbimortalidade, especialmente em áreas mais desfavoráveis. O objetivo deste estudo foi analisar as tendências e os padrões espaço-temporais da mortalidade relacionada à hanseníase no estado da Bahia, 1999-2014. Objetivo Analisar tendências e padrões espaço-temporais da mortalidade relacionada à hanseníase no Estado da Bahia de 1999 a 2014. Método Estudo de base populacional com dados secundários de mortalidade. Incluíram-se todos os óbitos em que a hanseníase foi mencionada como causa de morte. Resultados Foram registrados 1.152.262 óbitos, dos quais a hanseníase foi identificada em 481 (0,04%) casos, resultando em coeficiente bruto médio anual de mortalidade de 0,21 óbito/100 mil habitantes (intervalo de confiança [IC] de 95%: 0,13-0,29). Hanseníase não especificada (87,73%, ou 422/481) e complicações da hanseníase (6,44%, ou 31/481) foram as formas clínicas mais comumente mencionadas. O risco de óbito relacionado à hanseníase foi maior entre os homens (risco relativo [RR]: 2,38; IC 95%: 0,19-0,46), em idosos (RR: 74,79; IC 95%: 9,57-582,20) e na região oeste do Estado (RR: 4,08; IC 95%: 2,33-7,15). A mortalidade apresentou tendência temporal de aumento significativo no período ( Average Annual Percentual Change [AAPC] 7,3; IC 95%: 4,5 a 10,3), assim como a mortalidade proporcional (AAPC 5,3; IC 95%: 2,2 a 8,3). Conclusões A hanseníase representa uma causa negligenciada de óbito no Estado da Bahia. Apresenta tendências espaço-temporais desiguais nas regiões de saúde, com riscos associados, principalmente, à população masculina e idosa.

Uniform multidrug therapy for leprosy patients in Brazil (U-MDT/CT-BR): Results of an open label, randomized and controlled clinical trial, among multibacillary patients

Background

Leprosy control is based on early diagnosis and multidrug therapy. For treatment purposes, leprosy patients can be classified as paucibacillary (PB) or multibacillary (MB), according to the number of skin lesions. Studies regarding a uniform treatment regimen (U-MDT) for all leprosy patients have been encouraged by the WHO, rendering disease classification unnecessary.

Methodology and findings

An independent, randomized, controlled clinical trial conducted from 2007 to 2015 in Brazil, compared main outcomes (frequency of reactions, bacilloscopic index trend, disability progression and relapse rates) among MB patients treated with a uniform regimen/U-MDT (dapsone+rifampicin+clofazimine for six months) versus WHO regular-MDT/R-MDT (dapsone+rifampicin+clofazimine for 12 months). A total of 613 newly diagnosed, untreated MB patients with high bacterial load were included. There was no statistically significant difference in Kaplan-Meyer survival function regarding reaction or disability progression among patients in the U-MDT and R-MDT groups, with more than 25% disability progression in both groups. The full mixed effects model adjusted for the bacilloscopic index average trend in time showed no statistically significant difference for the regression coefficient in both groups and for interaction variables that included treatment group.

During active follow up, four patients in U-MDT group relapsed representing a relapse rate of 2.6 per 1000 patients per year of active follow up (95% CI [0·81, 6·2] per 1000). During passive follow up three patients relapsed in U-MDT and one in R-MTD. As this period corresponds to passive follow up, sensitivity analysis estimated the relapse rate for the entire follow up period between 2·9- and 4·5 per 1000 people per year.

Conclusion

Our results on the first randomized and controlled study on U-MDT together with the results from three previous studies performed in China, India and Bangladesh, support the hypothesis that UMDT is an acceptable option to be adopted in endemic countries to treat leprosy patients in the field worldwide.

Trial registration

ClinicalTrials.gov: NCT00669643

Since the introduction of multidrug therapy for leprosy in the 80’s, different classification criteria for leprosy patients have been proposed and treatment has been progressively shortened. Currently, leprosy patients are classified into paucibacillary/PB and multibacillary/MB based on the number of skins lesions. MB patients (over 5 skin lesions) receive three drugs (rifampicin, dapsone, clofazimine) for 12 months, while PB patients (up to 5 skin lesions) receive two drugs (rifampicin, dapsone) for 6 months. We conducted a randomized clinical trial to evaluate the efficacy of a uniform treatment (U-MDT) for both PB and MB leprosy patients, regardless any classification criteria. The current study includes results from: laboratory tests (bacilloscopic index/BI, serology and histopathology), clinical evaluation during a long follow-up, and uses adequate epidemiological analysis that gives robust evidence on main parameters used to evaluate the efficacy of U-MDT.

This study reports data among MB leprosy patients treated with regular/R-MDT and uniform/U-MDT regarding: (i) The frequency of leprosy reactions; (ii) BI decrease, (iii) Disability progression and (iv) Relapse. Overall, our results showed that there was no statistically significant difference in these outcomes for both treatment groups. In this sense, U-MDT can be considered as part of leprosy policy by control programs in endemic countries.

Minocycline in leprosy patients with recent onset clinical nerve function impairment

Nerve function impairment (NFI) in leprosy may occur and progress despite multidrug therapy alone or in combination with corticosteroids. We observed improvement in neuritis when minocycline was administered in patients with type 2 lepra reaction. This prompted us to investigate the role of minocycline in recent onset NFI, especially in corticosteroid unresponsive leprosy patients. Leprosy patients with recent onset clinical NFI (<6 months), as determined by Monofilament Test (MFT) and Voluntary Muscle Test (VMT), were recruited. Minocycline 100mg/day was given for 3 months to these patients. The primary outcome was the proportion of patients with 'restored,' 'improved,' 'stabilized,' or 'deteriorated' NFI. Secondary outcomes included any improvement in nerve tenderness and pain. In this pilot study, 11 patients were recruited. The progression of NFI was halted in all; with 9 out of 11 patients (81.82%) showing ?restored? or ?improved? sensory or motor nerve functions, on assessment with MFT and VMT. No serious adverse effects due to minocycline were observed. Our pilot study demonstrates the efficacy and safety of minocycline in recent onset NFI in leprosy patients. However, larger and long term comparative trials are needed to validate the efficacy of minocycline in leprosy neuropathy.