A global call for action to tackle skin-related neglected tropical diseases (skin NTDs) through integration: An ambitious step change

South-East Asia regional neglected tropical disease framework: improving control of mycetoma, chromoblastomycosis, and sporotrichosis

Mycetoma, chromoblastomycosis, and sporotrichosis are fungal neglected tropical diseases (NTDs) recognized by the World Health Organization. These implantation diseases cause substantial morbidity, disability, decreased quality of life, and can lead to long-term complications including tissue fibrosis, skin cancer, and amputation. The 2024-2030 South-East Asia Regional NTD Strategic Framework includes mycetoma but neglects the full extent of mycetoma endemicity in the region. Furthermore, the framework excludes chromoblastomycosis and sporotrichosis. We describe the data demonstrating fungal NTDs being of public health concern in this region and more widely distributed than acknowledged in the framework. Additionally, we propose modifications to public health interventions and services for fungal NTDs including an active case search approach through community health workers. Severe disease from fungal NTDs in South-East Asia can be eliminated by improving burden data quality, early diagnosis, accessible treatment, and integration with other common and neglected skin diseases.

Micronutrient-deficient diets and possible environmental enteric dysfunction in Buruli ulcer endemic communities in Ghana: Lower dietary diversity and reduced serum zinc and vitamin C implicate micronutrient status a possible susceptibility factor

BACKGROUND

The nutritional status of communities susceptible to Buruli ulcer (BU, a skin NTD caused by infection with Mycobacterium ulcerans) remains almost completely obscure. We have assessed the diets of BU patients vs. controls from the same BU-endemic communities, and compared their circulating biomarkers of nutrients and inflammation.

METHODS/PRINCIPAL FINDINGS

We investigated two cohorts of BU patients and controls. The first were administered food frequency and multi-pass 24-hour recall questionnaires to determine patterns of foods consumed, nutrient intake and nutrient adequacy. The second used archived serum samples collected as baseline to measure the circulating concentration of zinc, vitamin C, CRP, IL-1β, IFN-γ, TNF-α and IL-6. Stunted growth was more prevalent than expected (31%), while 18% of participants were underweight and most had inadequate intake of all micronutrients except for carbohydrate. BU patients had a lower intake of, selenium, vitamin B12 and zinc, and for selenium and vitamin B12 a higher proportion had dietary insufficiency (40% vs. 15% and 80% vs. 55%, respectively). In line with this, BU patients had significantly lower levels of zinc in their serum, and more had levels below the normal range (72% vs. 43%). Despite many participants having a good intake of vitamin C, serum levels were low, and lower amongst the BU patients. As expected, there was little evidence of systemic inflammation (CRP <0.6 mg/L). Elevated IL-6 levels were present in several participants suggesting that environmental enteric dysfunction may be prevalent in these communities, however this was similar in cases vs. controls.

CONCLUSIONS/SIGNIFICANCE

Diet and nutritional status may be a contributing factor to BU pathogenesis. Protein and the micronutrients zinc, selenium, vitamin B12 and vitamin C may be of particular importance. Nutritional interventions may have potential for both prophylaxis and treatment of BU, which may be a cost-effective approach to achieving the NTD Roadmap goals.

Buruli ulcer: An epidemiological update from Japan

Japan is one of the rare non-tropical countries with documented cases of Buruli ulcer (BU). Mycobacterium ulcerans subsp. shinshuense has been identified as the causative agent. The first report of BU in Japan dates back to 1982, with sporadic reports thereafter. Recently, the number of cases has been on the increase, and 50 cases (57.7%) are from the past decade alone, out of a total of 87 cases reported to date. Japan's well-developed healthcare facilities play a crucial role in enabling detailed investigations and providing appropriate treatment for patients, contributing to a favorable prognosis. However, the rarity of the disease results in lack of awareness among healthcare professionals, leading to frequent delays in diagnosis. This article aims to offer an updated overview of BU cases in Japan and to raise awareness of BU among dermatologists and other healthcare professionals in a non-endemic setting.

A systematic review and meta-analysis of the association between neglected tropical diseases and malnutrition: more research needed on diseases other than intestinal parasites, leishmaniasis and leprosy

Background. According to the World Health Organization, neglected tropical diseases (NTDs) affect over two billion people worldwide. While the links between nutrition and many diseases have become clear over recent decades, NTDs have lagged behind and the linkage with nutrition is largely unknown. We conducted this systematic review with meta-analysis to determine the current knowledge on the association between NTDs and malnutrition. Methodology. PubMed, Embase, Scopus and African Journals Online databases were searched using predefined search terms. We included all original articles with a case-control design and at least one NTD. The studies had to compare nutritional parameters between infected cases and control participants. Articles that did not report original data were excluded. The quality of the studies was assessed using the Newcastle-Ottawa scale. Pooled estimates were conducted using the random effect model. The publication bias of the studies was determined by funnel plots. Q and I 2 statistics were used to assess the heterogeneity of the studies. Results. After screening 1294 articles, only 16 qualified for the systematic review and 12 for meta-analysis. These predominately had a focus on soil-transmitted helminthiasis (ascariasis, hookworm diseases and trichuriasis) and schistosomiasis, with a minority concerning leishmaniasis and leprosy. Pooled estimates showed an association between intestinal parasites and stunting in children [odds ratio (OR) = 1.38, 95% confidence interval (CI): 1.14-1.66, I 2 = 0%, tau2 = 0]. We also identified a moderate association established between serum iron deficiency (OR = 4.67, 95% CI: 1.91-11.44, tau2 = 0) and intestinal parasites. Conclusions/significance. Of the 20 NTDs, the links between diet and disease have been explored for only 4. There is a paucity of data from low- and middle-income countries and least-developed countries where the NTD burden is high. Therefore, more research into the role of malnutrition in NTDs other than intestinal parasites, leishmaniasis and leprosy is needed.

Case Report: Cutaneous Leishmaniasis-A Hidden Disease in Côte d'Ivoire

Cutaneous leishmaniasis (CL) is classified as one of the skin-related neglected tropical diseases by the WHO. There have been limited reports of CL in Côte d'Ivoire, with fewer than 20 cases reported from Côte d'Ivoire in the literature since 1967, when it was first identified. Here, we report a case of CL originating in Côte d'Ivoire that we diagnosed during our active case finding activity in the Zounan Hounien District. The patient, a 15-year-old male, presented with multiple noninflammatory skin lesions on the face and trunk that had progressed from nodular to ulcerated lesions over the previous 3 months. Concurrent symptoms included fever, chest pain, cough, and malaise. Investigations for infectious diseases such as HIV and tuberculosis returned negative results. Histopathological analysis of a skin biopsy specimen from the nasal base demonstrated the presence of Leishman-Donovan bodies, confirming a diagnosis of CL. Although treatment with intralesional meglumine antimoniate (Glucantime) injections was intended, the drug could not be administered because the patient unfortunately died shortly after our consultation visit. Because of the rarity of CL in Côte d'Ivoire, awareness remains low, resulting in delayed diagnosis and treatment. Urgent strategies to improve awareness of CL among clinicians practicing in Côte d'Ivoire is required, first to appropriately diagnose and treat CL and second to generate epidemiological data of adequate quality.

Acid Fast Positivity Rate and Associated Factors of Leprosy in a Tertiary Care Hospital of Northeastern Ethiopia: Its Implication for Evidence-Based Leprosy Prevention and Control

Background and Aim

Leprosy is one of the most common skin neglected tropical diseases in Ethiopia posing social stigma, physical disability, deformity, discrimination, loss of social status, and poor quality of life in families. Hence, evidence-based collaborative inter-sectoral actions should be performed to reduce and eliminate its burden in endemic areas. Thus, the aim of this study was to assess the acid-fast positivity rate and associated factors of leprosy among suspected cases in Northeastern Ethiopia: a cross-sectional study.

Method

A cross-sectional study was conducted from September 2022 to March 2023 among 256 leprosy-suspected cases selected using a simple random sampling technique. A semi-structured questionnaire was used to collect socio-demographic, clinical, and predictor variables of leprosy through face-to-face interviews. Skin slit specimens were collected and stained using Ziehl-Neelsen staining technique. STATA 17 was used for analysis. The scale reliability coefficient was checked using Cronbach's α and the goodness-of-fit test of the model was assessed by the Hosmer-Lemshow test. Moreover, bivariable and multivariable logistic regression were computed. Finally, variables with an adjusted odds ratio and their p < 0.05 were taken as statistically significant.

Result

The mean ± standard deviation of the age of participants was 43.25 ± 16.35. The overall, prevalence of acid-fast positivity among suspected cases was 19.6% (95% CI: 15.8%, 23.4%). Multivariable logistic regression analysis showed that sex being male (p = 0.045), rural residence (p = 0.047), not eating three times meals frequency (p = 0.014), not eating a balanced diet (p = 0.036), poor personal hygiene (p = 0.028), distant from health facility (p = 0.039), not washing hands usually (p = 0.013), presence of current co-infection (p = 0.002), type of leprosy (p = 0.004), and close contact with leprosy cases (p = 0.003) were more likely to be positive for leprosy.

Conclusion

The prevalence of leprosy was remained high. Thus, early detection and treatment are necessary to reduce delayed diagnosis and hidden transmission of leprosy in the community. By addressing the driving factors through evidence-based intervention, we can significantly control the burden of leprosy in the affected communities, and improve their health outcomes and quality of life.

An integrated active case detection and management of skin NTDs in yaws endemic health districts in Cameroon, Côte d'Ivoire and Ghana

BACKGROUND

Integrated approaches to mapping skin Neglected Tropical Diseases (NTDs) may be cost-effective way to guide decisions on resource mobilization. Pilot studies have been carried out, but large-scale data covering multiple countries endemic for skin NTDs are lacking. Within the LAMP4YAWS project, we collected integrated data on the burden of multiple skin NTDs.

METHODS

From March 2021 to March 2023, integrated case searches for yaws alongside other skin conditions were performed in endemic health districts of yaws in Cameroon, Côte d'Ivoire, and Ghana. Integrated activities included training, social mobilization and active case detection. Initial screening involved a brief clinical examination of participants to determine if any skin conditions were suspected. Cases of skin NTDs were then referred to a health facility for appropriate management.

RESULTS

Overall 61,080 individuals screened, 11,387 (18.6%) had skin lesions. The majority of individuals (>90%) examined were children aged 15 years old and under. The proportion of serologically confirmed yaws cases was 8.6% (18/210) in Cameroon, 6.8% (84/1232) in Côte d'Ivoire, and 26.8% (440/1643) in Ghana. Other skin conditions based on clinical examination included: scabies, Buruli ulcer, leprosy, lymphatic filariasis (lymphoedema and hydrocele), tungiasis, and fungal infections. The most common conditions were scabies and superficial fungal infections. In Cameroon, scabies and superficial fungal infections accounted for 5.1% (214/4204) and 88.7% (3730/4204) respectively, 25.2% (1285/5095) and 50.4% (2567/5095) in Côte d'Ivoire. In Ghana, 20% (419/2090) of individuals had scabies but superficial fungal infections were not routinely recorded and were reported in only 1.3% (28/2090). Other skin NTDs were less common across all three countries.

CONCLUSION

This study confirms that integrated screening allows simultaneous detection of multiple skin NTDs, maximising use of scarce resources.

Diagnosing skin neglected tropical diseases with the aid of digital health tools: A scoping review

Delays in diagnosis and detection of skin neglected tropical diseases (NTDs) pose obstacles to prompt treatment, which is crucial in preventing disability. Recent developments in digital health have given rise to approaches that could increase access to diagnosis in resource-poor areas affected by skin NTDs. This scoping review provides an overview of current digital health approaches that aim to aid in the diagnosis of skin NTDs and provides an insight into the diverse functionalities of current digital health tools, their feasibility, usability, and the current gaps in research around these digital health approaches. This scoping review included a comprehensive literature search on PubMed, EMBASE and SCOPUS, following the PRISMA guidelines. Eleven studies were included in the review and were analysed using a descriptive thematic approach. Most digital tools were found to be mobile-phone based, such as mobile Health (mHealth) apps, store-and-forward tele-dermatology, and Short Messaging Service (SMS) text-messaging. Other digital approaches were based on computer software, such as tele-dermatopathology, computer-based telemedicine, and real-time tele-dermatology. Digital health tools commonly facilitated provider-provider interactions, which helped support diagnoses of skin NTDs at the community level. Articles which focused on end-user user experience reported that users appreciated the usefulness and convenience of these digital tools. However, the results emphasized the existing lack of data regarding the diagnostic precision of these tools, and highlighted various hurdles to their effective implementation, including insufficient infrastructure, data security issues and low adherence to the routine use of digital health tools. Digital health tools can help ascertain diagnosis of skin NTDs through remote review or consultations with patients, and support health providers in the diagnostic process. However, further research is required to address the data security issues associated with digital health tools. Developers should consider adapting digital health tools to diverse socio-cultural and technical environments, where skin NTDs are endemic. Researchers are encouraged to assess the diagnostic accuracy of digital health tools and conduct further qualitative studies to inform end-user experience. Overall, future studies should consider expanding the geographical and disease scope of research on digital health tools which aid the diagnosis of skin NTDs.

The psychosocial impacts of skin-neglected tropical diseases (SNTDs) as perceived by the affected persons: A systematic review

BACKGROUND

Neglected Tropical Diseases (NTDs) disproportionately affect marginalised groups within impoverished communities, conferring devastating physical, financial and psychosocial effects. Skin-NTDs (SNTDs) are uniquely stigmatising due to their visible nature, rendering affected individuals vulnerable to psychosocial risk and the associated decline in social participation, quality of life and mental health. In response to knowledge gaps identified by current global efforts for integrated control of SNTDs this review gathers existing evidence on the psychosocial effects of SNTDs, with consideration given to the influence of gender.

METHODS

The study protocol is registered with PROSPERO (CRD42022336676). Data was collected from Embase, Global Health, Medline and Web of Science, with additional articles identified through Google Scholar and bibliography tracking. Qualitative studies published in English between 2005 and 2024 reporting men's and women's experiences with SNTDs were searched. Appropriate data from each included study were inputted into NVivo software to facilitate thematic synthesis. Descriptive and analytic themes were generated through line-by-line coding using an inductive approach.

RESULTS

27 articles of high and moderate quality were included. They pertained to buruli ulcer, cutaneous leishmaniasis, leprosy, lymphatic filariasis, tungiasis, onchocerciasis, schistosomiasis and podoconiosis. Men and women across SNTDs and contexts reported debilitating physical symptoms which impaired their ability to work, socialise and carry out usual daily activities. Some felt (at least initially) well supported by partners and relatives, whereas most experienced avoidance, abandonment and even violence, with women incurring worse SNTD-related social consequences. Many men and most women experienced stigma, with discriminatory behaviours largely attributed to fear of infection, decreased ability to perform gender-specific daily activities, and the perceived association between SNTDs and sinfulness. Self-reported impacts of SNTDs on men's and women's mental wellbeing included low mood, anxiety, low self-esteem, and suicidal ideation. Disease-specific knowledge, early treatment, social support, and disease acceptance were mentioned as protective factors.

CONCLUSION

SNTDs cause significant psychosocial harms, particularly for women. Implementing myth-busting and contact-based educational campaigns and improving access to treatment and to livelihood opportunities and social protection schemes for men and women with a SNTD will help prevent and mitigate these.

Is there a growing global threat of scabies treatment failure? An opportunity to discuss health inequity within UK dermatology

This editorial addresses the rising number of scabies cases seen globally, including within Europe. The authors address scabies treatment failure as a potential contributing factor and the reasons behind this. The authors go on to address the wider social and economic detriments of health in the UK and how these need to be addressed if we are to successfully tackle the rising number of scabies cases.

Stigma associated with cutaneous and mucocutaneous leishmaniasis: A systematic review

BACKGROUND

Cutaneous (CL) and mucocutaneous leishmaniasis (MCL) are parasitic diseases caused by parasites of the genus leishmania leading to stigma caused by disfigurations. This study aimed to systematically review the dimensions, measurement methods, implications, and potential interventions done to reduce the CL- and MCL- associated stigma, synthesising the current evidence according to an accepted stigma framework.

METHODS

This systematic review followed the PRISMA guidelines and was registered in PROSPERO (ID- CRD42021274925). The eligibility criteria included primary articles discussing stigma associated with CL and MCL published in English, Spanish, or Portuguese up to January 2023. An electronic search was conducted in Medline, Embase, Scopus, PubMed, EBSCO, Web of Science, Global Index Medicus, Trip, and Cochrane Library. The mixed methods appraisal tool (MMAT) was used for quality checking. A narrative synthesis was conducted to summarise the findings.

RESULTS

A total of 16 studies were included. The studies report the cognitive, affective, and behavioural reactions associated with public stigma. Cognitive reactions included misbeliefs about the disease transmission and treatment, and death. Affective reactions encompass emotions like disgust and shame, often triggered by the presence of scars. Behavioural reactions included avoidance, discrimination, rejection, mockery, and disruptions of interpersonal relationships. The review also highlights self-stigma manifestations, including enacted, internalised, and felt stigma. Enacted stigma manifested as barriers to forming proper interpersonal relationships, avoidance, isolation, and perceiving CL lesions/scars as marks of shame. Felt stigma led to experiences of marginalisation, rejection, mockery, disruptions of interpersonal relationships, the anticipation of discrimination, fear of social stigmatisation, and facing disgust. Internalised stigma affected self-identity and caused psychological distress.

CONCLUSIONS

There are various manifestations of stigma associated with CL and MCL. This review highlights the lack of knowledge on the structural stigma associated with CL, the lack of stigma interventions and the need for a unique stigma tool to measure stigma associated with CL and MCL.