Evidence for hidden leprosy in a high leprosy-endemic setting, Eastern Ethiopia: The application of active case-finding and contact screening

Measuring leprosy case detection delay and associated factors in Indonesia: a community-based study

BACKGROUND

Leprosy is a public health burden in Indonesia with a high number of new cases every year and a high proportion of disability among new cases. Case detection delay (CDD) can contribute to ongoing transmission and increased disability chances among leprosy patients. This study aimed to establish the CDD of leprosy and the factors associated with detection delay in Indonesia.

METHOD

Community-based study with a cross-sectional design. Data were collected through interviews about sociodemographic and behavioral factors, anticipated stigma, and duration of CDD. Leprosy classification and case detection methods were obtained from health service records. A random sample was taken of 126 leprosy patients registered between 1st October 2020 and 31st March 2022 in the Tegal regency in the Central Java Province. Data were analysed by descriptive and analytical statistics using multiple linear regression.

RESULTS

The mean CDD, patient delay, and health system delay were 13.0 months, 9.7 months, and 3.2 months, respectively. Factors associated with longer CDD are younger age (below 35 years), male, found through passive case detection, and not having a family member with leprosy. Factors associated with longer patient delay were being younger (below 35 years), being male, not having a family member with leprosy, and anticipated stigma of leprosy. It was not possible to reliably identify factors associated with health system delay.

CONCLUSION

CDD in leprosy should be reduced in Indonesia. The Indonesian National Leprosy Control Program (NLCP) is advised to adopt an integrated intervention programme combining active case detection with targeted health education to reduce CDD and thereby preventing disabilities in people affected by leprosy.

Effectiveness of population-wide screening and mass drug administration for leprosy control in Kiribati: the COMBINE protocol

INTRODUCTION

Progress towards leprosy elimination is threatened by increasing incidence in 'hot-spot' areas where more effective control strategies are urgently required. In these areas, active case finding and leprosy prevention limited to known contacts is insufficient for control. Population-wide active case-finding together with universal prevention through mass drug administration (MDA) has been shown to be effective in 'hot-spot' areas, but is logistically challenging and expensive. Combining leprosy screening and MDA with other population-wide screening activities such as for tuberculosis may increase programme efficiency. There has been limited evaluation of the feasibility and effectiveness of combined screening and MDA interventions. The COMBINE study aims to bridge this knowledge gap.

METHODS AND ANALYSIS

This implementation study will assess the feasibility and effectiveness of active leprosy case-finding and treatment, combined with MDA using either single-dose rifampicin or rifamycin-containing tuberculosis preventive or curative treatment, for reducing leprosy incidence in Kiribati. The leprosy programme will run over 2022-2025 in concert with population-wide tuberculosis screening-and-treatment in South Tarawa. The primary research question is to what extent the intervention reduces the annual leprosy new case detection rate (NCDR) in adults and children compared with routine screening and postexposure prophylaxis (PEP) among close contacts (baseline leprosy control activities). Comparisons will be made with (1) the preintervention NCDR separably among adults and children in South Tarawa (before-after study) and (2) the corresponding NCDRs in the rest of the country. Additionally, the postintervention prevalence of leprosy obtained from a survey of a 'hot-spot' sub-population will be compared with prevalence documented during the intervention. The intervention will be implemented in collaboration with the Kiribati National Leprosy Programme.

ETHICS AND DISSEMINATION

Approval has been obtained from the Kiribati Ministry of Health and Medical Services (MHMS), the University of Otago (H22/111) and the University of Sydney (2021/127) Human Research Ethics Committees. Findings will be shared with the MHMS, local communities and internationally through publication.

Prolonged delays in leprosy case detection in a leprosy hot spot setting in Eastern Ethiopia

Background

Leprosy or Hansen’s disease is known to cause disability and disfigurement. A delay in case detection of leprosy patients can lead to severe outcomes. In Ethiopia, the disability rates caused by leprosy among new cases are relatively high compared to other endemic countries. This suggests the existence of hidden leprosy cases in the community and a delay in timely detection. To reduce disability rates, it is crucial to identify the factors associated with this delay. This study aimed to determine the extent of delay in case detection among leprosy cases in Eastern Ethiopia.

Methods

This cross-sectional explorative study was conducted in January and February 2019 among 100 leprosy patients diagnosed ≤6 months prior to inclusion. A structured questionnaire was used to collect data, including the initial onset of symptoms, and the reasons for delayed diagnosis. Descriptive statistics, including percentages and medians, were used to describe the case detection delay. Logistic regression analysis was carried out to evaluate the predictors of delay in case detection of >12 months.

Findings

The median age of patients was 35 years, with a range of 7 to 72 years. The majority were male (80%) and rural residents (90%). The median delay in case detection was 12 months (interquartile range 10–36 months) among the included patients. The mean delay in case detection was 22 months, with a maximum delay of 96 months. The overall prevalence of disability among the study population was 42% (12% grade I and 30% grade II). Fear of stigma (p = 0.018) and experiencing painless symptoms (p = 0.018) were highly associated with a delay in case detection of >12 months.

Conclusions

Being afraid of stigma and having painless symptoms, which are often misinterpreted as non-alarming at the onset of the disease, were associated with a delay in case detection. This study showed the need to increase knowledge on early symptoms of leprosy among affected communities. Furthermore, it is important to support initiatives that reduce leprosy related stigma and promote health worker training in leprosy control activities.

Leprosy, also called Hansen’s disease, is a chronic infectious disease that may result in devastating disabilities. The disability rate among new leprosy patients in Ethiopia is high compared to other countries. A delay in case detection is a major factor contributing to the development of disability. Late diagnosis also fosters ongoing transmission, increasing the incidence of the disease. We aimed to determine the extent of the detection delay and find the reasons for this delay in eastern Ethiopian districts, endemic for leprosy. One hundred leprosy patients who recently started multi-drug therapy were included in the study. The median detection delay was one year among all patients. About half of the patients had sought treatment from health institutions within one year after the onset of their first symptoms. Longer delays among leprosy patients were associated with a fear of stigma and painless symptoms at an early stage of the disease. This indicates that it is vital to improve community knowledge of leprosy symptoms and to take initiatives that reduce stigma. This should improve health-seeking behaviour and may prevent the development of disability as well as halt transmission.

Acid-Fast Bacilli Positivity Rate and Associated Factors among Leprosy Suspected Cases attending Selected Health Facilities located in West Arsi Zone, Oromia, Ethiopia

Introduction

Leprosy is one of the neglected tropical diseases that affect skin and peripheral nervous system often results in severe, lifelong disabilities and deformities. Even though multidrug therapy was in place for more than 30 years to treat and prevent leprosy worldwide including Ethiopia, its epidemiology is not well studied in the West Arsi zone.

Objective

The aim of this study was to determine the prevalence of acid-fast bacilli (AFB) positivity rate and associated factors among leprosy suspected cases.

Methods

A health facility-based cross-sectional study was conducted among 422 leprosy suspected cases from August 2020 to December 2020. To detect AFB, skin slit specimens were collected and examined using the Ziehl-Neelsen staining technique. Socio-demographic and clinical data were collected using a structured questionnaire. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 24. Logistic regression was employed to determine predictors of AFB positivity rate.

Results

Acid-fast bacilli were detected among 46 leprosy suspected cases which gives a prevalence of 10.9% with 95% CI (8.2‒15.6). Suspected leprosy cases with multibacillary type were 4 times more likely to be AFB positive (p=0.021) than their counterparts. Study participants who had contact with known leprosy cases were 2 times more likely to be AFB positive (p = 0.032) and those with no formal education were 2 times more likely to be AFB positive (p = 0.03). Participants who had close contact with leprosy patients for ≥3 years were 8 times more likely to be AFB positive (p = 0.02).

Conclusion

This study revealed a high prevalence of AFB positivity rate in the era of multidrug therapy. Types of leprosy, close contact with known leprosy cases, educational status, and duration of closer contact with leprosy cases were significantly associated with AFB positivity rate.