Leprosy and cutaneous leishmaniasis affecting the same individuals: A retrospective cohort analysis in a hyperendemic area in Brazil

Time trend and identification of risk areas for physical disability due to leprosy in Brazil: An ecological study, 2001-2022

BACKGROUND

Leprosy is a chronic infectious disease that affects the peripheral nerves, leading to neurological damage and physical disability. This study analyzed the temporal trend in the rate of new leprosy cases with grade 2 physical disability in Brazil and identified spatial clusters of risk for physical disability.

METHODS

This is an ecological study of all new cases of leprosy with grade 2 physical disability (G2D) at diagnosis between 2001 and 2022 in Brazil, macro-regions, states and municipalities. Data were extracted from the National System of Notifiable Diseases and the Brazilian Institute of Geography and Statistics. Sociodemographic and clinical variables such as age, sex, race/colour, education and clinical form of the disease were analyzed, as well as the rate of new cases of leprosy with grade 2 physical disability at the time of diagnosis per million inhabitants. Data analysis was divided into three stages: 1- Descriptive analysis of the socio-demographic and clinical profile; 2- Time series analysis: In this stage, the joint-point regression model was used; 3- Spatial analysis, using global and local Moran statistics.

RESULTS

There were 50,466 new cases of leprosy with G2D during the period studied, 97.4% aged > 14 years, 70.2% male, 45.7% brown, 87.6% with low education, 90.2% multibacillary and 47.5% dimorphic clinical form. There was a downward trend in the detection of leprosy with physical disability grade 2, with an average annual reduction of 2.8% (13.6/1 million in 2001 and 9.1/1 million in 2022). The southeast, south and north regions showed a downward trend. A total of 14 states and 4 capitals showed a decrease in the rate, the most significant being Roraima (-11.0%/year). Tocantins was the only state with an upward trend (3.2%/year). 635 (14.1%) municipalities were in the high-high quadrant. These municipalities belong to 12 Brazilian states and accounted for 30% (n = 15,139) of all cases recorded in the country over the 22 years analyzed.

CONCLUSIONS

These results suggest an overall decrease in the detection of leprosy with physical disability in Brazil and highlight geographical disparities in the occurrence of leprosy disability. Interventions to promote early diagnosis should be targeted at areas with the highest rate of new cases with grade 2 disability.

Understanding experiences of neglected tropical diseases of the skin: a mixed-methods study to inform intervention development in Ethiopia

BACKGROUND

The WHO and Ethiopia's Ministry of Health have developed strategies to expand and integrate services for co-endemic neglected tropical diseases (NTDs) which manifest in the skin. To inform these strategies, we aimed to understand the social, economic and health system context of skin NTD care in Kalu woreda, Amhara region, Ethiopia, where cutaneous leishmaniasis (CL) and leprosy are endemic.

METHODS

Between October 2020 and May 2022, we surveyed and reviewed records of 41 primary healthcare facilities and explored common disease experiences in focus group discussions (n=40) and interviews with people affected by leprosy (n=37) and CL (n=33), health workers (n=23), kebele authorities and opinion leaders (n=33) and traditional healers (n=7). Opportunities for integrated skin NTD service provision were explored through policy document review, interviews with health officials (n=25), and stakeholder meetings.

RESULTS

Availability of diagnostic supplies and health worker competence to provide skin care was very limited across primary healthcare facilities, particularly for CL. People with leprosy commonly sought care from healthcare facilities, while people with CL administered self-care or sought help from traditional healers. Travel and costs of care at specialised facilities outside the district inhibited timely care-seeking for both diseases. Transmission discourses shaped different understandings of who was affected by leprosy and CL and expectations of behaviour during and after treatment. Many policy actors felt that existing supply chain interventions, decentralised treatment approaches and community engagement initiatives for leprosy could also benefit CL, but others also warned against increasing care-seeking unless CL treatment could be provided on a scale commensurate with the large burden they perceived.

CONCLUSION

Our findings demonstrate significant gaps in the provision of care for skin NTDs within primary healthcare, very different health-seeking patterns for leprosy and CL, and a need to develop new models of care, especially for CL.

Measuring social vulnerability in communities and its association with leprosy burden through spatial intelligence in central West Brazil to guide strategic actions

BACKGROUND

It is known that leprosy is a socially determined disease, but most studies using spatial analysis have not considered the vulnerabilities present in these territories.

OBJECTIVES

To measure the association between social vulnerability and the burden of leprosy in the urban space of Cuiabá.

METHODS

Ecological study, carried out in Cuiabá, Brazil. Diagnosed cases of leprosy were surveyed through the Notifiable Diseases Information System, from 2008 to 2018. The spatial scan statistics technique of leprosy cases per each Human Development Unit was applied. Social vulnerability was measured based on the Municipal Human Development Index (MHDI), education level and average per capita income. For the spatial correlation between vulnerability and leprosy, Global and local bivariate Moran's index was used.

RESULTS

8389 cases of leprosy were georeferenced, the majority being male (58%), 30% of cases were not evaluated for degree of physical disability. One of the spatial scan clusters had a relative risk (RR) of 6.93 (95% CI 6.49-7.4), and another had 1360 cases with RR 1.71 (95% CI 1.62-1.82). The bivariate global autocorrelation of Moran's index for MHDI was 0.579, observing 1 High-High in the East region and 1 in South, for education the index was 0.429, 2 High-High in the East and 1 in the South, and 0.145 for average per capita income, 1 High-High in the East.

CONCLUSION

There was a spatial association between leprosy cases and territories with low MHDI, having a percentage of the population without schooling and/or with low income. The study advances knowledge by presenting characteristics of territories most affected by leprosy, verifying the spatial correlation of the disease with the recurrent socioeconomic characteristics in these territories.

IgG seroprevalence of Toxoplasma gondii and Leishmania infantum in leprosy patients: Implications for screening and management of co-infections

Parasitic co-infections are common in developing countries and can interfere with leprosy treatment, leading to an increased risk of inflammatory leprosy reactions. This study assessed serum immunoglobulin G (IgG) levels against Toxoplasma gondii and Visceral Leishmaniasis (VL) antigens in 270 leprosy patients from Brazilian states. Regarding the respective cut-offs, the prevalence of IgG seropositivity for T. gondii and VL were 21.05 % and 47.36 % in the leprosy-negative group, and 77.7 % and 52.6 % in the leprosy-positive group. Of the 270 leprosy patients, 158 (58.5 %) presented with inflammatory leprosy reactions. Of those, 72 (59.5 %) had neuritis, 35 (48.6 %) had reverse reactions, and 28 (38.9 %) had ENL in both Brazilian states. Leprosy patients with anti-Leishmania IgG seropositivity were 3.25 times more likely to develop neuritis (95 % C.I.: 1.187 - 9.154; p = 0.019). These findings are particularly relevant for clinical settings where both leprosy and parasitic diseases are prevalent and could provide essential guidance for detecting and addressing complications arising from parasitic co-infections in leprosy patients, thereby improving clinical management strategies.

Intra-urban differences underlying leprosy spatial distribution in central Brazil: geospatial techniques as potential tools for surveillance

This ecological study identified an aggregation of urban neighbourhoods spatial patterns in the cumulative new case detection rate (NCDR) of leprosy in the municipality of Rondonópolis, central Brazil, as well as intra-urban socioeconomic differences underlying this distribution. Scan statistics of all leprosy cases reported in the area from 2011 to 2017 were used to investigate spatial and spatiotemporal clusters of the disease at the neighbourhood level. The associations between the log of the smoothed NCDR and demographic, socioeconomic, and structural characteristics were explored by comparing multivariate models based on ordinary least squares (OLS) regression, spatial lag, spatial error, and geographically weighted regression (GWR). Leprosy cases were observed in 84.1% of the neighbourhoods of Rondonópolis, where 848 new cases of leprosy were reported corresponding to a cumulative NCDR of 57.9 cases/100,000 inhabitants. Spatial and spatiotemporal high-risk clusters were identified in western and northern neighbourhoods, whereas central and southern areas comprised low-risk areas. The GWR model was selected as the most appropriate modelling strategy (adjusted R²: 0.305; AIC: 242.85). By mapping the GWR coefficients, we identified that low literacy rate and low mean monthly nominal income per household were associated with a high NCDR of leprosy, especially in the neighbourhoods located within high-risk areas. In conclusion, leprosy presented a heterogeneous and peripheral spatial distribution at the neighbourhood level, which seems to have been shaped by intra-urban differences related to deprivation and poor living conditions. This information should be considered by decision-makers while implementing surveillance measures aimed at leprosy control.

Integrated control of neglected tropical diseases in Brazil: document review of a national campaign in light of WHO recommendations

Objective

To describe the results of a national campaign aimed at the integrated control of neglected tropical diseases in Brazil in light of the World Health Organization (WHO) official documentation related to the integration of strategies for the prevention, control, and elimination or eradication of neglected tropical diseases.

Methods

A document review that included official WHO documents published between 2007 and 2020 and campaign results extracted from the official technical report produced by the Brazilian Ministry of Health.

Results

The integrated control of neglected tropical diseases was gradually incorporated in the WHO documentation over time. Preventive chemotherapy through mass drug administration, intensified case management, and integrated vector management were extensively recommended as strategies for integrated control. The Brazilian campaign was carried out in four iterations between 2013 and 2017. Children aged 5 to 14 years enrolled in municipal public schools nationwide were targeted. In summary, a total of 1 074 and 73 522 new cases of leprosy and trachoma, respectively, were detected. Nearly 18 million doses of preventive chemotherapy for soil-transmitted helminthiasis were administered. More than 700 cases of schistosomiasis were diagnosed and treated.

Conclusions

The integrated strategies implemented in Brazil throughout the campaign generated results aligned with the WHO recommendations for the control of neglected tropical diseases, especially those regarding mass drug administration, active case detection, and intensified case management. Therefore, the continuity of the campaign with adequate evaluation tools must be encouraged as a constant public health policy in the Brazilian government agenda.

Bacterial, fungal and parasitic co-infections in leprosy: A scoping review

BACKGROUND

In leprosy patients, the most commonly reported non-viral co-infections are Tuberculosis, Leishmaniasis, Chromoblastomycosis and Helminths. The presence of a secondary infection is believed to increase the likelihood of leprosy reactions. The purpose of this review was to describe the clinical and epidemiological characteristics of the most reported bacterial, fungal, and parasitic co-infections in leprosy.

METHODOLOGY/PRINCIPAL FINDINGS

Following the PRISMA Extension for Scoping Reviews guidelines, a systematic literature search was conducted by two independent reviewers, resulting in the inclusion of 89 studies. For tuberculosis, a total of 211 cases were identified, with a median age of 36 years and male predominance (82%). Leprosy was the initial infection in 89% of cases, 82% of individuals had multibacillary disease, and 17% developed leprosy reactions. For leishmaniasis, 464 cases were identified, with a median age of 44 years and male predominance (83%). Leprosy was the initial infection in 44% of cases, 76% of individuals presented with multibacillary disease, and 18% developed leprosy reactions. Regarding chromoblastomycosis, we identified 19 cases with a median age of 54 years and male predominance (88%). Leprosy was the primary infection in 66% of cases, 70% of individuals had multibacillary disease, and 35% developed leprosy reactions. Additionally, we found 151 cases of co-infection with leprosy and helminths, with a median age of 43 years and male predominance (68%). Leprosy was the primary infection in 66% of cases, and 76% of individuals presented with multibacillary disease, while the occurrence of leprosy reactions varied from 37% to 81% across studies.

CONCLUSION

We observed a male-dominated pattern of co-infections among working-age individuals with multibacillary leprosy. Unlike prior studies reporting increased leprosy reactions in chronic viral co-infections, our findings did not indicate any increase among bacterial, fungal, or parasitic co-infections. Rather, co-infections with tuberculosis and leishmaniasis appeared to reduce leprosy reactions.

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.