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Background: Leprosy, caused by Mycobacterium leprae, affects multiple body systems and can lead to preventable disability if untreated. While multidrug therapy (MDT) has been available since 1982, historical evidence suggests that untreated leprosy can resolve spontaneously. Nevertheless, the prevalence of self-healing worldwide, as well as factors determining self-healing, remain unclear. Methods: A systematic review was conducted in 2023 with data from PubMed, Infolep, and Web of Sciences data bases, along with a google search. Data extraction and analysis followed PRISMA guidelines and were summarized in a separate Excel sheet. Included were English-language studies on self-healing in leprosy, regardless the year of publication. Results: We included six studies spanning from 1938 to 1978 exploring the incidence of self-healing in different countries and continents. Children, paucibacillary (PB) cases, and possibly males showed a higher probability of self-healing with an average healing time of two years. Discussion/Conclusion: Recent research on self-healing in leprosy is scarce and evidence limited. This is primarily due to ethical concerns regarding withholding effective treatment of diagnosed patients, and because of the absence of an agreed definition of self-healing. Nevertheless, self-healing appears to be a plausible phenomenon influenced by geographic and demographic factors, and the type of leprosy. We recommend further research on self-healing in leprosy, as it provides insight into the human immune system and the determinants of this phenomenon. More insight could help adapt clinical practices and public health strategies, thereby contributing to an effective management and control of this disease. Author summary: Leprosy, a chronic infectious disease caused by Mycobacterium leprae, presents significant health challenges worldwide, with the potential for avoidable disabilities if left untreated. While MDT has substantially reduced the disease burden since its introduction in 1982, historical records suggest that some cases of leprosy exhibit spontaneous resolution without medical intervention. However, the prevalence of self-healing globally and the factors influencing this phenomenon remain unclear. The review identified six studies conducted between 1938 and 1978, which examined the occurrence of self-healing in various countries. These studies revealed that children and individuals with PB leprosy demonstrated a higher likelihood of self-healing, typically within an average period of two years. Despite the limited recent evidence due to ethical considerations, self-healing appears to be a plausible phenomenon influenced by patient-specific characteristics and the type of leprosy infection. Ultimately, this paper presents a compelling case for future research on self-healing in leprosy, as it provides an interesting view on the human immune system as well as the determinants of this phenomenon. Our recommendations emphasize the necessity of such investigations to adapt clinical practices and public health strategies, thereby contributing to an effective management and control of this disease. [ABSTRACT FROM AUTHOR]

Background: Leprosy is a chronic infectious disease neglected, caused by Mycobacterium leprae, considered a public health problem because may cause permanent physical disabilities and deformities, leading to severe limitations. This review presents an overview of the results of epidemiological studies on leprosy occurrence in childhood in Brazil, aiming to alert health planners and managers to the actual need to institute special control strategies. Methodology/Principal findings: Data collection consisted of an electronic search for publications in eight databases: Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scientific Electronic Library Online (SciELO), PuBMed, Biblioteca Virtual em Saúde (BVS), SciVerse Scopus (Scopus), CAPES theses database, CAPES journals database and Web of Science of papers published up to 2016. After apply selection criteria, twenty-two papers of studies conducted in four different regions of Brazil and published between 2001 and 2016 were included in the review. The leprosy detection rate ranged from 10.9 to 78.4 per 100,000 inhabitants. Despite affecting both sexes, leprosy was more common in boys and in 10-14-year-olds. Although the authors reported a high cure proportion (82–90%), between 1.7% and 5.5% of the individuals developed a disability resulting from the disease. Conclusions/Significance: The findings of this review shows that leprosy situation in Brazilian children under 15 years is extremely adverse in that the leprosy detection rate remains high in the majority of studies. The proportion of cases involving disability is also high and reflects the difficulties and the poor effectiveness of actions aimed at controlling the disease. The authors suggest the development of studies in spatial clusters of leprosy, where beyond the routine actions established, are included news strategies of active search and campaigns and actions of educations inside the clusters of this disease. The new agenda needs to involve the precepts of ethical, humane and supportive care, in order to achieve a new level of leprosy control in Brazil. Author summary: Leprosy remains as a severe health problem in Brazil and its transmission in children under 15 years of age occurs mainly through intradomiciliary contacts. The number of leprosy cases in this age group is considered an important indicator for the surveillance of this disease. To understand how the epidemiological studies in Brazil have shown the situation of young people affected by leprosy, we performed a systematic review of the literature, searching for published articles about the situation of leprosy in this age group. We reviewed 22 studies published during 2001 to 2016 and concluded that the negative effects of leprosy still remain high in most of studied places in Brazil. This disease was more common in boys, aged between 10 to 14 years old, with a remarkable proportion of disabilities due to leprosy. These disabilities can limit their routine activities and reflect failure in the public medical care. We hope that our review should contribute to arguments in order to improve the control of this disease in children. [ABSTRACT FROM AUTHOR]

Introduction: Pure Neural Leprosy (PNL) is a rare clinical form of leprosy in which patients do not present with the classical skin lesions but have a high burden of the disability associated with the disease. Clinical characteristics and follow up of patients in PNL are still poorly described in the literature. Objective: This paper aims to describe the clinical, electrophysiological and histopathological characteristics of PNL patients, as well as their evolution after multidrug therapy (MDT). Methods: Fifty-two PNL patients were selected. Clinical, nerve conduction studies (NCS), histopathological and anti-PGL-1serology were evaluated. Patients were also assessed monthly during the MDT. At the end of the MDT, all of the patients had a new neurological examination and 44 were submitted to another NCS. Results: Paresthesia was the complaint most frequently reported by patients, and in the neurological examination the most common pattern observed was impairment in sensory and motor examination and a mononeuropathy multiplex. Painful nerve enlargement, a classical symptom of leprosy neuropathy, was observed in a minority of patients and in the motor NCS axonal injuries, alone or in combination with demyelinating features, were the most commonly observed. 88% of the patients did not present any leprosy reaction during MDT. There was no statistically significant difference between the neurological examinations, nor the NCS pattern, performed before and after the MDT. Discussion: The classical hallmarks of leprosy neuropathy are not always present in PNL making the diagnosis even more challenging. Nerve biopsy is an important tool for PNL diagnosis as it may guide therapeutic decisions. This paper highlights unique characteristics of PNL in the spectrum of leprosy in an attempt to facilitate the diagnosis and management of these patients. Author summary: Neuropathy is responsible for most of the disability associated with leprosy disease. The pure neural leprosy (PNL), in spite of being a rare clinical presentation of that, has some singular characteristics that are still poorly studied. In this study, we selected 52 patients at the diagnosis to describe their clinical, neurophysiological and histopathological presentation patterns as well as their evolution during the multidrug therapy (MDT). We confirmed that sensitive symptoms were the most commonly described by PNL patients but neural pain is rare. Also confirmed that mononeuropathy mutiplex was the most common pattern observed at neurological examination and at the nerve conduction studies at the moment of the diagnosis. However we showed that painful nerve enlargement other cardinal signs of leprosy, besides the skin lesions, is not common in this group of patients, There was no statistically significant difference between the neurological examination and NCS performed before and after the MDT.During the MDT88.4% of the patients did not have any leprosy reaction. This may suggest that that MDT was effective in stopping disease progression. Our results highlight the difficulties in the diagnosis of PNL and the progression following MDT in an attempt to prevent further disability in PNL patients. [ABSTRACT FROM AUTHOR]

Background: In new leprosy cases, grade 2 disability (G2D) is still a public health burden worldwide. It is often associated with the delayed leprosy diagnoses that healthcare systems should play a crucial role in preventing. The aim of this systematic review was to identify healthcare factors related to delays in case detection in leprosy. Methods: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) was used as a guideline in this research. The study protocol was registered in the PROSPERO (International Prospective Register of Systematic Reviews) with reference code CRD42020189274. Data was collected from five electronic databases: Embase.com, Medline All Ovid, Web of Science, Cochrane CENTRAL, and the WHO Global Health Library. Results: After applying the selection criteria for original empirical studies, and after removing duplicates, we included 20 papers from 4313 records. They had been conducted in ten countries and published between January 1, 2000, and January 31, 2021. We identified three categories of healthcare factors related to delayed case. 1) Structural factors, such as i) financial and logistic issues, and geographical circumstances (which we classified as barriers); ii) Health service organization and management including the level of decentralization (classified as facilitators). 2) Health service factors, such as problems or shortages involving referral centers, healthcare personnel, and case-detection methods. 3) Intermediate factors, such as misdiagnosis, higher numbers of consultations before diagnosis, and inappropriate healthcare services visited by people with leprosy. Conclusions: Delays in leprosy case detection are due mainly to misdiagnosis. It is crucial to improve the training and capacity of healthcare staff. To avoid misdiagnosis and reduce detection delays, national leprosy control programs should ensure the sustainability of leprosy control within integrated health services. Author summary: New leprosy patients diagnosed with visible physical deformities represent a significant disease burden that also poses an important public health challenge. The physical deformities often result from long delays in case detection. Greater insight into the healthcare factors that contribute to such delays will support the development of effective prevention programs. We therefore reviewed all studies on the healthcare factors related to case-detection delay that had been published between January 1, 2000, and January 31, 2021. Twenty studies were included in our analysis. We found that misdiagnosis was a core healthcare factor related to delays. Other common factors included inappropriate health services, a high number of consultations before diagnosis; and a lack of referral centers, healthcare personnel, and case-detection methods. Detection delay was further influenced by geographical circumstances, financial and logistic issues, and health-service organization and management including the level of the decentralization of healthcare programs. Because delays in leprosy case detection are due mainly to misdiagnosis, we recommend to improve the training and capacity of healthcare staff. To avoid misdiagnosis and reduce detection delays, national leprosy control programs should ensure the sustainability of leprosy control within integrated health services. [ABSTRACT FROM AUTHOR]

Leprosy, or Hansen's disease, is one of the oldest infectious diseases in the world. It has long been associated with stigma and discrimination, but only in recent years has this aspect been formally recognized by the international community as a human rights issue. The UN Human Rights Council first adopted a resolution on leprosy in 2008, and this was later followed by a UN General Assembly resolution in 2010. Nonbinding principle and guidelines on elimination of discrimination against persons affected by leprosy and their family members accompanied the 2010 resolution, but these have yet to be fully implemented. In 2017, the Human Rights Council appointed a Special Rapporteur on leprosy to investigate the extent to which the principles and guidelines have been implemented, and her term was extended for a further 3 years in 2020. Considering the proper implementation of the principles and guidelines to be key to eliminating the discrimination that persons affected by leprosy and their families face in various parts of the world, this paper looks at the contribution the Special Rapporteur can make. Based on an assessment of her activities to date, it concludes that the Special Rapporteur has actively worked to build networks with persons affected by leprosy and related organizations and gain their trust, but has faced challenges in organizing official country visits. It goes on to analyze what sort of legacy the Special Rapporteur should aim to leave behind after completing her second term and how she can go about doing so in the time remaining. To this end, it makes 5 suggestions: (1) gather information systematically on the actual situation of discrimination; (2) compile a collection of success stories; (3) ensure that there is consistency between legally binding international covenants and treaties and the principles and guidelines; (4) present proposals for concrete actions that can be taken after the Special Rapporteur's second term ends; and (5) initiate a feasibility study on creating an "index" and "indicators" to measure the current status of stigma and discrimination and the extent to which the principles and guidelines have been implemented. [ABSTRACT FROM AUTHOR]

Background: The number of new leprosy cases is declining globally, but the disability caused by leprosy remains an important disease burden. The chance of disability is increased by delayed case detection. This review focusses on the individual and community determinants of delayed leprosy case detection. Methods: This study was conducted according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). The study protocol is registered in PROSPERO (code: CRD42020189274). To identify determinants of delayed detection, data was collected from five electronic databases: Embase.com, Medline All Ovid, Web of Science, Cochrane CENTRAL, and the WHO Global Health Library. Results: We included 27 papers from 4315 records assessed. They originated in twelve countries, had been published between January 1, 2000, and January 31, 2021, and described the factors related to delayed leprosy case detection, the duration of the delayed case, and the percentage of Grade 2 Disability (G2D). The median delay in detection ranged from 12 to 36 months, the mean delay ranged from 11.5 to 64.1 months, and the percentage of G2D ranged from 5.6 to 43.2%. Health-service-seeking behavior was the most common factor associated with delayed detection. The most common individual factors were older age, being male, having a lower disease-symptom perception, having multibacillary leprosy, and lack of knowledge. The most common socioeconomic factors were living in a rural area, performing agricultural labor, and being unemployed. Stigma was the most common social and community factor. Conclusions: Delayed leprosy case detection is clearly correlated with increased disability and should therefore be a priority of leprosy programs. Interventions should focus on determinants of delayed case detection such as health-service-seeking behavior, and should consider relevant individual, socioeconomic, and community factors, including stigmatization. Further study is required of the health service-related factors contributing to delay. Author summary: Leprosy remains an important public health problem with many new leprosy patients diagnosed with visible physical deformities, indicating a long delay in the detection of cases. For effective prevention programs, it is important to know the factors at the level of the individual and the community that contribute to the delay. We reviewed all published studies that reported individual and community factors related to delayed case detection in leprosy and included 27 studies in our analysis, published between January 1, 2000, and January 31, 2021. Health-service-seeking behavior was the most common factor associated with delay in case detection. The most common individual factors were older age, being male, having a lower disease-symptom perception, having multibacillary leprosy, and lack of knowledge about leprosy. The most common socioeconomic factors were living in a rural area, performing agricultural labor, and being unemployed. Stigma was the most common social and community factor associated with detection delay. The presence of physical disability in newly diagnosed leprosy patients is clearly related to the delay in detecting these patients. Leprosy control interventions should take factors related to detection delay into account more comprehensively. Also, there is a need to study health service-related factors that contribute to detection delay of leprosy patients. [ABSTRACT FROM AUTHOR]

Leprosy, podoconiosis, and lymphatic filariasis (LF) are among the priority neglected tropical diseases (NTDs) in Ethiopia. The disability, psychosocial, and mental health status of people affected by these NTDs are still overlooked in global NTD discourse. The objective of this systematic review was to synthesize the existing evidence describing the disability, psychosocial, and mental health status of people affected by leprosy, podoconiosis, and LF prior to developing a holistic physical and psychosocial care package for these individuals. We searched papers reporting on disability, psychosocial, and mental health status linked to these 3 NTDs. The protocol was registered in PROSPERO with registration number CRD42019128400. Peer-reviewed articles were searched and extracted from Medline, PsycINFO, Global Health, and Embase. Articles published in English, irrespective of the year of publication, using a quantitative study methodology, were included. Abstracts and full texts were reviewed by 2 reviewers. Data were extracted and narratively summarized, as the studies were heterogeneous and used different outcome measures. Out of 1,318 titles/abstracts screened and 59 full text studies reviewed, 24 fulfilled the inclusion criteria. Fourteen studies provided evidence of the disability associated with leprosy, podoconiosis, or LF. Ten studies provided evidence on the association between the 3 NTDs and mental health or psychosocial outcomes. The prevalence of grade 2 disability varied from 3.9% to 86%. The most commonly reported mental health impacts were depression and mental distress. A high burden of mental illness was reported, varying from 12.6% to 71.7%; the suicidal ideation was also high (18.5%). In conclusion, disability and poor psychosocial and mental health status are associated with leprosy, podoconiosis, and LF. For optimum management of these NTDs, holistic care including both physical and psychosocial interventions is vital. Author summary: Podoconiosis, lymphatic filariasis (LF), and leprosy are neglected tropical diseases (NTDs) that are commonly found among disadvantaged rural and some poor urban communities. These diseases lead to disabilities of the leg, which may result in reduced productivity. The longer the duration of the disease, the more severe the disability. People affected by these diseases also commonly experience stigma and discrimination, which, in turn, affect health-seeking behavior. Due to this disability, stigma, and discrimination, people affected by these 3 NTDs have a poor quality of life. We also found a range of mental health problems related to these 3 NTDs. Among these, the most common were mental distress and depression. As all 3 NTDs are associated with poor physical, psychosocial, and mental health outcomes, management should be holistic, incorporating physical, psychosocial, and mental health interventions. Following this review, we are working on the development of a holistic integrated care package for people affected by leprosy, podoconiosis, and LF in northwestern Ethiopia. [ABSTRACT FROM AUTHOR]

Background: Despite elimination efforts, the number of Mycobacterium leprae (M. leprae) infected individuals who develop leprosy, is still substantial. Solid evidence exists that individuals living in close proximity to patients are at increased risk to develop leprosy. Early diagnosis of leprosy in endemic areas requires field-friendly tests that identify individuals at risk of developing the disease before clinical manifestation. Such assays will simultaneously contribute to reduction of current diagnostic delay as well as transmission. Antibody (Ab) levels directed against the M.leprae-specific phenolic glycolipid I (PGL-I) represents a surrogate marker for bacterial load. However, it is insufficiently defined whether anti-PGL-I antibodies can be utilized as prognostic biomarkers for disease in contacts. Particularly, in Bangladesh, where paucibacillary (PB) patients form the majority of leprosy cases, anti-PGL-I serology seems an inadequate method for leprosy screening in contacts as a directive for prophylactic treatment. Methods: Between 2002 and 2009, fingerstick blood from leprosy patients’ contacts without clinical signs of disease from a field-trial in Bangladesh was collected on filter paper at three time points covering six years of follow-up per person. Analysis of anti-PGL-I Ab levels for 25 contacts who developed leprosy during follow-up and 199 contacts who were not diagnosed with leprosy, was performed by ELISA after elution of bloodspots from filter paper. Results: Anti-PGL-I Ab levels at intake did not significantly differ between contacts who developed leprosy during the study and those who remained free of disease. Moreover, anti-PGL-I serology was not prognostic in this population as no significant correlation was identified between anti-PGL-I Ab levels at intake and the onset of leprosy. Conclusion: In this highly endemic population in Bangladesh, no association was observed between anti-PGL-I Ab levels and onset of disease, urging the need for an extended, more specific biomarker signature for early detection of leprosy in this area. Trial registration: ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

Background: The province of Formosa, Argentina, is endemic for leprosy. In the present paper, we assessed the trend (T, 2002–2016 time series) and the forecast for 2022 of new case detection rate (NCDR) and determined the spatial distribution of new cases detected (NCD) of leprosy. Methodology/Principal findings: This is a descriptive observational study of 713 NCD of leprosy from provincial medical records between January 2002 and December 2016. The whole dataset from the provincial medical record was used to independently estimate the NCDR trends of the general population, age groups, sexes and Departments. This same database was used to estimate the NCDR forecast of the general population for 2022, applying a dynamic linear model with a local linear trend, using the MCMC algorithm. The NCDR was higher in men (p<0.05), increased with age (0.20, 8.17, 21.04, and 29.49 for the 0–14, 15–44, 45–64 and over 65-year-old age groups, respectively; p<0.05) and showed a downward trend (negative values) of estimated slopes for the whole province and each Department. Bermejo Department showed the highest (T:-1.02, 95%CI: [-1.42, -0.66]) and Patiño the lowest decreasing trend (T:-0.45, 95%CI: [-0.74, -0.11]). The NCDR trend for both sexes was similar (T:-0.55, 95%CI: [-0.64, -0.46]), and age groups showed a decreasing trend (S15-44:-103, S45-64:-81, S>65:-61, p<0.05), except for the 0–14 age group (S:-3, p>0.05), which showed no trend. Forecasts predicted that leprosy will not be eliminated by 2022 (3.64, 95%CI: [1.22, 10.25]). Conclusions/Significance: Our results highlight the status of leprosy in Formosa and provide information to the provincial public health authorities on high-risk populations, stressing the importance of timely detection of new cases for further elimination of the disease in the province. Author summary: Leprosy, a neglected tropical disease, is a public health problem in northern Argentina, causing permanent damage, stigmatization and discrimination. The Program for the Control of Leishmaniasis and Leprosy in Formosa province (PCLyLF) is responsible for the diagnosis and treatment of the disease and the active search for household contacts. The present study aimed to determine the spatial distribution of new cases of leprosy and the status of the disease using new case detection rate (NCDR) as the main epidemiological indicator. We determined the NCDR trends (2002–2016 time series) of the general population, age groups, sexes and Departments, and the NCDR forecast for the province by 2022. Our results indicated that leprosy was spread throughout Formosa, with higher rates in men and in patients over 65 years old. The NCDR showed a downward trend in the whole province and in each Department. The Departments of Bermejo and Matacos had the highest decreasing trend and the Department of Patiño the lowest one. Future projections show that leprosy will not be eliminated by 2022. [ABSTRACT FROM AUTHOR]

Background: There is no point of care diagnostic test for infection with M. Leprae or for leprosy, although ELISA anti PGL-1 has been considered and sometimes used as a means to identify infection. Methods: A systematic review of all cohort studies, which classified healthy leprosy contacts, at entry, according to anti-PGL1 positivity, and had at least one year follow up. The outcome was clinical diagnosis of leprosy by an experienced physician. The meta-analysis used a fixed model to estimated OR for the association of PGL-1 positivity and clinical leprosy. A fixed model also estimated the sensibility of PGL-1 positivity and positive predictive value. Results: Contacts who were anti PGL-1 positive at baseline were 3 times as likely to develop leprosy; the proportion of cases of leprosy that were PGL-1 positive at baseline varied but was always under 50%. Conclusions: Although there is a clear and consistent association between positivity to anti PGL-1 and development of leprosy in healthy contacts, selection of contacts for prophylaxis based on anti PGL1 response would miss more than half future leprosy cases. Should chemoprophylaxis of controls be incorporated into leprosy control programmes, PGL1 appears not to be a useful test in the decision of which contacts should receive chemoprophylaxis. [ABSTRACT FROM AUTHOR]

Introduction: Leprosy and lymphatic filariasis (LF) are among the most disabling neglected tropical diseases (NTDs) that affect the citizens of Mozambique, especially in the Northern provinces. The irreversible impairments caused by these NTDs often lead to psychosocial consequences, including poor mental wellbeing, stigma and reduced social participation. Limited data on these consequences are available for Mozambique, which are urgently needed to better understand the true disease burden and support advocacy for scaling up interventions. Methods: A cross-sectional mixed-methods study was conducted. Mental distress was assessed with the Self Reporting Questionnaire (SRQ-20), participation restriction was assessed with the Participation Scale Short (PSS) and perceived stigma was assessed with the Explanatory Model Interview Catalogue affected persons stigma scale (EMIC-AP). Additionally, semi-structured interviews were conducted with persons affected by leprosy or LF. Results: In total, 127 persons affected by leprosy and 184 persons affected by LF were included in the quantitative portion of the study. For the qualitative portion, eight semi-structured interviews were conducted. In both disease groups, mental distress was found in 70% of participants. Moreover, 80% of persons affected by leprosy and 90% of persons affected by LF perceived stigma. Moderate to extreme participation restriction was found in approximately 43% of persons affected by leprosy and in 26% of the persons affected by LF. Persons affected by leprosy and LF felt excluded from society and experienced financial problems. More severe disabilities were associated with more severe outcomes for mental wellbeing, participation restriction and stigma. By contrast, participation in a self-care group was suggested to have a positive impact on these outcomes. Conclusion: The findings provide evidence that persons affected by leprosy and LF must not only confront physical impairments but also experience significant disability in the psychosocial domain, including mental distress, participation restriction and stigma. These challenges must be urgently addressed by NTD programmes to promote the inclusion and wellbeing of persons affected by NTDs. Author summary: Leprosy and lymphatic filariasis (LF) are severe tropical diseases that affect over 1 billion people worldwide, especially in poor regions. In Mozambique, where 11 neglected tropical diseases (NTDs) are common, there is limited information about the impact of leprosy and LF on people's mental and social wellbeing. The current study, which occurred in northern Mozambique, with support from NLR Mozambique and health authorities, aims to understand this impact. The research team examined mental distress, participation restriction and stigma using surveys and interviews. In total, 127 persons affected by leprosy and 184 persons affected by LF were included in the quantitative portion of the study. In addition, eight semi-structured interviews were conducted. Our findings showed that many participants face mental distress (70%), participation restriction (55%) and health-related stigma (86%), with the severity of leprosy and LF linked to greater challenges. Moreover, our analysis revealed that disability, stigma and marital status played a significant role in the presence or absence of psychosocial challenges. Participation in self-care groups was suggested to have a positive impact on mental and social wellbeing. Despite some limitations, our study highlights the urgent need for better mental and social support for persons affected by disabling NTDs. It is crucial to address mental health, promote inclusion and adapt services to local needs. To this end, we recommend more research with diverse groups and suggest the integration of mental health care into programmes for NTDs. This study emphasises the importance of looking after the overall wellbeing of those affected by leprosy and LF in Mozambique. [ABSTRACT FROM AUTHOR]

Background: Stigma plays in an important role in the lives of persons affected by neglected tropical diseases, and assessment of stigma is important to document this. The aim of this study is to test the cross-cultural validity of the Community Stigma Scale (EMIC-CSS) and the Social Distance Scale (SDS) in the field of leprosy in Cirebon District, Indonesia. Methodology/principle findings: Cultural equivalence was tested by assessing the conceptual, item, semantic, operational and measurement equivalence of these instruments. A qualitative exploratory study was conducted to increase our understanding of the concept of stigma in Cirebon District. A process of translation, discussions, trainings and a pilot study followed. A sample of 259 community members was selected through convenience sampling and 67 repeated measures were obtained to assess the psychometric measurement properties. The aspects and items in the SDS and EMIC-CSS seem equally relevant and important in the target culture. The response scales were adapted to ensure that meaning is transferred accurately and no changes to the scale format (e.g. lay out, statements or questions) of both scales were made. A positive correlation was found between the EMIC-CSS and the SDS total scores (r = 0.41). Cronbach's alphas of 0.83 and 0.87 were found for the EMIC-CSS and SDS. The exploratory factor analysis indicated for both scales an adequate fit as unidimensional scale. A standard error of measurement of 2.38 was found in the EMIC-CSS and of 1.78 in the SDS. The test-retest reliability coefficient was respectively, 0.84 and 0.75. No floor or ceiling effects were found. Conclusions/significance: According to current international standards, our findings indicate that the EMIC-CSS and the SDS have adequate cultural validity to assess social stigma in leprosy in the Bahasa Indonesia-speaking population of Cirebon District. We believe the scales can be further improved, for instance, by adding, changing and rephrasing certain items. Finally, we provide suggestions for use with other neglected tropical diseases. Author Summary: Persons affected by neglected tropical diseases, such as, Buruli ulcer, lymphatic filariasis, onchocerciasis, leishmaniasis and leprosy, can experience stigma. One important source of stigma are members in the community. Neighbours, religious leaders, and community leaders can exclude, reject, blame or devalue a person affected by one of these diseases. It is important to be able to assess this type of stigma for the prevention and management of these diseases. Assessing stigma is not an easy task. There are several instruments available, but these were developed with different aims or tested in different settings. We can use these instruments, but we need to be sure that they assess what we want them to assess and whether the instrument produces consistent results. In this paper the authors report a study that investigated the validity of two scales that assess stigma in the community towards people affected by leprosy in Indonesia. The names of the scales are Explanatory Model Interview Catalogue Community Stigma Scale (EMIC-CSS) and Social Distance Scale (SDS). The results show the two scales to be adequately valid and reliable in the target culture. There are, however, also several improvements possible and the authors provide suggestions how to incorporate these. In addition, the authors provide recommendations for the use of these scales among people affected by other neglected tropical diseases. [ABSTRACT FROM AUTHOR]

Introduction: Assessment of attitude of health care professionals is important as negative attitude could constitute a major deterrent to care-seeking by persons affected by neglected tropical diseases (NTDs) such as leprosy. Leprosy continues to pose a major disease burden in India with an annual new case detection rate of 10.17 per 100,000 population. This paper reports on the development and validation of a culturally appropriate scale to measure attitude of health care providers (HCPs) towards persons affected by leprosy in Tamil Nadu, India. Methodology/Principal findings: The Affective, Behavioural and Cognitive (ABC) model of attitudes guided the development of the scale. Steps in scale development included qualitative interviews and focus group discussions with medical officers and paramedical staffs selected from high prevalence districts in Tamil Nadu, India which informed the development of the draft scale. Reviews of existing attitude questionnaires in related areas further contributed to scale development and together helped to generate a large pool of items which was then subjected to Thurston’s scaling method for selection of items from this pool. Face and content validity were obtained, following which internal consistency and test, re-test reliability were assessed. Scaling exercise resulted in 11 items being discarded from an initial pool of 38, owing to the poor agreement among experts regarding relevance. Face and content validity were good with experts endorsing relevance and applicability of items. The intra-class correlation coefficient (ICC) for test re-test reliability of the 27 item scale was 0.6 (95% CI: 0.20–0.78) indicating marginal intra-class correlation. The overall Cronbach’s alpha was 0.85 while the alphas for each of the affective and behavioural components was good at 0.78 and 0.69 respectively indicating a good degree of consistency and homogeneity between items but the alpha for the cognitive component was low at 0.53. Conclusions: The ABC model of attitudes guided the development of the scale, ensured a mix of 27 items tapping into the three domains of Affect, Behaviour and Cognition which best explained the attitude construct. With good validity and alphas for each of the affective, behavioural components and overall alpha estimates, this scale can be a valuable tool to provide accurate estimates of the true attitudes held by HCPs. This, in turn, would be useful to obtain insights for appropriate intervention programmes that would help change negative attitudes of HCPs towards persons affected by leprosy. With some adaptations, the scales can be validated for other NTDs as well. [ABSTRACT FROM AUTHOR]

Background: Leprosy is a condition that has long been associated with stigma and discrimination, even when infected persons have been cured. This paper describes stigma and discrimination as viewed by caregivers who are associated with people affected by leprosy in Ghana. Methods: A qualitative interview with semi-structured interviews were conducted for twenty caregivers. Results: Findings indicated that caregivers were of the view that people affected by leprosy in Ghana are stigmatized and discriminated against by the larger society thus making their movements and interactions restricted to the Leprosarium. Besides, employments opportunities are unavailable to them thus making them exposed to financial challenges. The livelihood Empowerment Against poverty (LEAP) money given them is not sufficient for their daily upkeep. Conclusion: People affected by leprosy in Ghana are stigmatized and therefore find it difficult to interact freely with the public. The associated physical deformities with the disease also tend to impede their ability to relate to the general public. The LEAP cash given to people affected by leprosy is helpful however, it could be enhanced to keep pace with prevailing economic conditions in the country. [ABSTRACT FROM AUTHOR]

Background: There are several studies on thyroid functions and thyroid gland features in patients with leprosy in the literature. The relationship between them have not been clarified yet. These studies are time-expired and don't contain ultrasonography examination. The purpose of the study is to investigate thyroid functions and gland characteristics in leprosy patients by ultrasonography (US) and current laboratory techniques. Patients and Methods: This retrospective study was conducted by collecting the data of patients with lepramatous leprosy. Serum thyroid-stimulating hormone, free triiodothyronine, free thyroxine, anti-thyroid peroxidase, antithyroglobulin, and thyroglobulin values and thyroid ultrasonography reports were collected from previous records. Results: The mean age is 75.12±9.89 years of total 17 subjects and 10 patients (58.8%) were male. Thyroid US was performed on 14 of the patients, nodules were detected in a total of 7 (50%) patients. The mean FT3, FT4, TSH, Anti-Tpo, Anti-TG, and TG values of the patients were found to be within normal limits. Conclusion: In the present study, no changes were detected in the thyroid functions and structures of the patients with Lepromatous Leprosy. We consider that prospective randomized studies that will include larger sample sizes are needed to determine whether there is a relationship between leprosy and thyroid disease. Author summary: Leprosy is also known as Hansen's disease, caused by the bacillus Mycobacterium leprae. This ancient disease continues to be a serious healt problem worldwide. Currently it is more common in subtropical regions. Although leprosy cases are decreasing, they are still seen in Turkey. Mycobacterium Leprae lead to an chronic granulamatous infection mainly on skin and peripheral nerves however, it can also affect other tissues such as eyes, mucous membranes, bones and testicles, and may occur different clinical manifestations. It has been shown that it also causes changes in endocrine organ functions. There are some studies on thyroid functions, but the effects of leprosy on thyroid functions and structure are not clear. In this study, we examined the structural features and functional status of the thyroid gland, in a small number of patients because of Leprosy is non endemic common in our country. No changes were detected in the thyroid functions and structures of the patients with Lepromatous Leprosy in a thyroid-endemic region in this study. We consider that it is necessary prospective randomized studies included larger sample sizes on this topic [ABSTRACT FROM AUTHOR]

The International Classification of Function, Disability, and Health (ICF—WHO, 2001) recognizes several dimensions of disability, such as body structure and function (and impairment thereof), activity (and activity restrictions) and participation (and participation restriction) and their interactions with contextual factor (personal and environmental). In this study, we map and analyse the relationship between the components of ICF in leprosy patients from two rural areas in Indonesia: Lewoleba (East Nusa Tenggara) and Likupang (North Minahasa). This study was part of a community outreach program by the KATAMATAKU team from Universitas Indonesia. The body structure was graded using the WHO hand and feet disability grade and the number of enlarged nerves, while the body function was measured by the Jebsen Taylor Hand Function Test (JTT) and Timed-up and Go (TUG). Activity limitation and participation restriction were measured using the Screening Activity Limitation Safety Awareness (SALSA) Scale and Participation Scale (P-scale), respectively. There were 177 leprosy patients from the two regions and 150 patients with complete data were included in the analysis. We found 82% (95% CI: 75.08%-87.32%) of subjects with multibacillary leprosy, 10.67% (95% CI: 6.67%-16.62%) of subjects with grade 2 WHO hand disability, and 9.33% (95% CI: 5.64%-15.06%) of subjects with grade 2 WHO foot disability. Assessment using the SALSA Scale showed 29.33% of subjects with limitation activity and 11.33% with participation restriction. Age was shown to have positive correlations with SALSA, JTT, and TUG. Inter-dimensional analysis showed that the SALSA scale had significant positive correlations with the number of nerve enlargements, P-scale, JTT, and TUG. SALSA scores of grade 2 WHO hand and foot disability were also significantly higher than grades 1 and 0. The participation scale also had a positive correlation with JTT but not TUG. Hand disability seemed to affect societal participation while foot did not. We used the ICF to describe and analyse dimensions of leprosy-related disability in Indonesia. Author summary: Disability is the long-term outcome of untreated leprosy or Hansen's disease, which is caused by peripheral nerve invasion of the Mycobacterium leprae. It is a serious and life-limiting complication for leprosy patients. Currently, seven regions in Indonesia have not yet achieved the state of disease elimination. In addition, Indonesia has not succeeded in achieving the sub-target of the rate of new cases with grade 2 disability in 2023. The concept of disability and health including the body structure, body function, personal and environmental domains, activity limitation, and participation restriction, is provided by the ICF. Through the framework, we could assess the aspects of disability and its relationship to one another in leprosy patients. Furthermore, the early detection, screening, and management programs for leprosy have not included aspects of disability and rehabilitative measures for restoration. Thus, the purpose of this study is to find the impact of leprosy-related disability on the patients' body function, activity, and participation. We reported 150 leprosy patients from two rural areas of Indonesia and found significant relationships between specific indicators, which would be useful for rehabilitative management programs in the future. [ABSTRACT FROM AUTHOR]

Introduction: Neglected tropical diseases (NTDs) mainly affect underprivileged populations, potentially resulting in catastrophic health spending (CHS) and impoverishment from out-of-pocket (OOP) costs. This systematic review aimed to summarize the financial hardship caused by NTDs. Methods: We searched PubMed, EMBASE, EconLit, OpenGrey, and EBSCO Open Dissertations, for articles reporting financial hardship caused by NTDs from database inception to January 1, 2023. We summarized the study findings and methodological characteristics. Meta-analyses were performed to pool the prevalence of CHS. Heterogeneity was evaluated using the I2 statistic. Results: Ten out of 1,768 studies were included, assessing CHS (n = 10) and impoverishment (n = 1) among 2,761 patients with six NTDs (Buruli ulcer, chikungunya, dengue, visceral leishmaniasis, leprosy, and lymphatic filariasis). CHS was defined differently across studies. Prevalence of CHS due to OOP costs was relatively low among patients with leprosy (0.0–11.0%), dengue (12.5%), and lymphatic filariasis (0.0–23.0%), and relatively high among patients with Buruli ulcers (45.6%). Prevalence of CHS varied widely among patients with chikungunya (11.9–99.3%) and visceral leishmaniasis (24.6–91.8%). Meta-analysis showed that the pooled prevalence of CHS due to OOP costs of visceral leishmaniasis was 73% (95% CI; 65–80%, n = 2, I2 = 0.00%). Costs of visceral leishmaniasis impoverished 20–26% of the 61 households investigated, depending on the costs captured. The reported costs did not capture the financial burden hidden by the abandonment of seeking healthcare. Conclusion: NTDs lead to a substantial number of households facing financial hardship. However, financial hardship caused by NTDs was not comprehensively evaluated in the literature. To develop evidence-informed strategies to minimize the financial hardship caused by NTDs, studies should evaluate the factors contributing to financial hardship across household characteristics, disease stages, and treatment-seeking behaviors. Author summary: Neglected tropical diseases (NTDs) mainly affect underprivileged populations, potentially resulting in catastrophic health spending (CHS) and impoverishment from out-of-pocket (OOP) costs. This systematic review aimed to summarize the financial hardship caused by NTDs. We found that NTDs lead to a substantial number of households facing financial hardship. CHS risk due to direct OOP costs was relatively low among patients with leprosy (0.0–11.0%), dengue (12.5%), and lymphatic filariasis (0.0–23.0%), and relatively high among patients with Buruli ulcers (45.6%). CHS risk varied widely among patients with chikungunya (11.9–99.3%) and visceral leishmaniasis (24.6–91.8%). Costs of visceral leishmaniasis impoverished 20–26% of 61 households, depending on the costs captured. Nevertheless, financial hardship caused by NTDs was not comprehensively evaluated in the literature. Therefore, to develop evidence-informed strategies to minimize the financial hardship caused by NTDs, studies should evaluate the factors contributing to financial hardship across household characteristics, disease stages, and treatment-seeking behaviors. [ABSTRACT FROM AUTHOR]

Introduction: Autologous blood products like Platelet Rich Plasma (PRP) and Leukocyte and Platelets Rich Fibrin (L-PRF) have been used for many years across many types of skin ulcers. However, the effectiveness of autologous blood products on wound healing is not well established. Methods: We evaluated the 'second generation' autologous product- Leukocyte and Platelet- Rich Fibrin (L-PRF). Our trial was undertaken on patients suffering from neuropathic leprosy ulcers at the Anandaban hospital which serves the entire country of Nepal. We conducted a 1:1 (n = 130) individually randomised trial of L-PRF (intervention) vs. normal saline dressing (control) to compare rate of healing and time to complete healing. Rate of healing was estimated using blind assessments of ulcer areas based on three different measurement methods. Time to complete healing was measured by the local unblinded clinicians and by blind assessment of ulcer images. Results: The point estimates for both outcomes were favourable to L-PRF but the effect sizes were small. Unadjusted mean differences (intervention vs control) in mean daily healing rates (cm2) were respectively 0.012 (95% confidence interval 0.001 to 0.023, p = 0.027); 0.016 (0.004 to 0.027, p = 0.008) and 0.005 (-0.005 to 0.016, p = 0.313) across the three measurement methods. Time to complete healing at 42 days yielded Hazard Ratios (unadjusted) of 1.3 (0.8 to 2.1, p = 0.300) assessed by unblinded local clinicians and 1.2 (0.7 to 2.0, p = 0.462) on blind assessment. Conclusion: Any benefit from L-PRF appears insufficient to justify routine use in care of neuropathic ulcers in leprosy. Trial registration: ISRCTN14933421. Date of trial registration: 16 June 2020. Author summary: Autologous Blood Products such as Leucocyte and Platelets Rich Fibrin (L-PRF) gel have been widely used in the treatment of skin ulcers, including Leprosy ulcers. L-PRF gel contains a high concentration of platelets and leucocytes rich in growth factors that might promote wound healing. However, our systematic review showed that there is a lack of high-quality trial evidence for the effectiveness of L-PRF. To evaluate the efficacy of L-PRF we conducted an individual randomised controlled trial (n = 130) of L-PRF gel vs conventional normal saline dressings. Photographs were taken during twice weekly dressing changes in both intervention and control groups. The ulcer photographs were assessed by blinded assessors using three different ulcer area measurement methods. Outcomes were rate of healing and time to complete epithelialisation. Point estimates for intervention effects across outcomes and measurement methods, intervention vs control was favorable to L-PRF but the effect sizes were small and mostly not statistically significant. [ABSTRACT FROM AUTHOR]

Background: This paper assesses the impact of a counselling intervention on reducing leprosy-related stigma in Cirebon District, Indonesia. The unique features of this intervention are its rights-based approach, the underlying Cognitive Behavioural Therapy (CBT) model, the three types of counselling and the lay and peer counsellors who were involved. Methodology/principal findings: Mixed methods (e.g. three scales, interviews, focus group discussions and reflection notes) were used to assess the impact of the intervention, which ran over a two-year period. There was a control area with no interventions. The study participants were people affected by leprosy and other key persons (e.g. family members). The sample size differs per method, for example, data regarding 67 counselling clients and 57 controls from a cohort, and notes from 207 counselling clients were examined. The notes showed that most clients faced stigma on a daily basis, whether internalized, anticipated and/or enacted. A significant reduction was found between the before and after total scores of the SARI Stigma Scale (p-value < 0.001), Participation Scale Short (p-value < 0.001) and WHO Quality of Life score (p-value < 0.001) among the counselling clients. While there is also an effect in the control group, it is much larger in the intervention group. Qualitative data indicates that knowledge and rights trigger change. Clients took steps to improve their life such as re-connecting with neighbours, helping in household activities and applying for jobs. Challenges include the wish to conceal their condition. Conclusion/significance: The findings show that the counselling intervention was effective in reducing stigma, promoting the rights of people with leprosy and facilitating their social participation. More research is needed on how to create a more sustainable intervention, preferably structurally embedded in the health or social services. [ABSTRACT FROM AUTHOR]

Leprosy is an infectious disease characterized by slow and chronic evolution, caused by Mycobacterium leprae and or Mycobacterium lepromatosis, an intracellular alcohol-acid-resistant (BAAR) bacillus. The objective of this study was to provide an epidemiological, clinical, and geographic characterization of leprosy in the city of Santarém-Pará during the period 2011–2020. A cross-sectional, descriptive, and quantitative approach was used, employing maps and tables to illustrate clinical and epidemiological variables, including: sex, age, race, area of residence, operational classification, clinical form, number of skin lesions, number of affected nerves, and health units. During the analyzed period, 581 cases of leprosy were diagnosed, resulting in the following cumulative incidence rates: male (60%); age over 15 years (94%); urban area (73%); multibacillary (74%); borderline form (46%); skin lesions greater than 5 (34%); and no nerves affected (68%). In the urban perimeter, a higher cumulative incidence of cases was observed in the central area with 133 cases. However, the health unit reporting the largest number of cases belonged to the southern area, specifically the Basic Health Unit of Nova República, with 48 cases. This study highlights the need to characterize the nuances of leprosy and its variability within the urban environment, according to different areas. Further research is essential to inform the implementation of public policies aimed at addressing the population with the highest vulnerability index, thereby reducing leprosy rates in Santarém. Author summary: This article addresses the incidence of leprosy in Santarém, Brazil, during the COVID-19 pandemic. In 2020, there was a 41% reduction in cases compared to the average between 2015 and 2019, possibly due to the cancellation and rescheduling of appointments, affecting diagnoses and follow-up. Men constituted 60% of the cases, with their hesitation to seek care associated with late diagnoses. Alarmingly, 6% of patients were under 14 years old, indicating possible intrafamilial transmission. Socioeconomic and ethnic inequalities were evident, with 74% of cases in individuals of mixed race. The article emphasizes the importance of addressing leprosy not only as a public health challenge but also as a reflection of social and economic inequalities in Brazil. It proposes comprehensive health policies, expansion of medical services in remote regions, and educational initiatives for awareness and early diagnosis, especially in vulnerable communities. The association between age and clinical form of the disease, as well as spatial distribution analyses, provides crucial insights for developing targeted prevention and treatment strategies. [ABSTRACT FROM AUTHOR]

Background: Can deliberate interaction between the public and persons affected by leprosy reduce stigmatization? The study described in this paper hypothesises that it can and assesses the effectiveness of a ‘contact intervention’. Methods/Principal Findings: This cluster-randomized controlled intervention study is part of the Stigma Assessment and Reduction of Impact (SARI) project conducted in Cirebon District, Indonesia. Testimonies, participatory videos and comics given or made by people affected by leprosy were used as methods to facilitate a dialogue during so-called ‘contact events’. A mix of seven quantitative and qualitative methods, including two scales to assess aspects of stigma named the SDS and EMIC-CSS, were used to establish a baseline regarding stigma and knowledge of leprosy, monitor the implementation and assess the impact of the contact events. The study sample were community members selected using different sampling methods. The baseline shows a lack of knowledge about leprosy, a high level of stigma and contrasting examples of support. In total, 91 contact events were organised in 62 villages, directly reaching 4,443 community members (mean 49 per event). The interview data showed that knowledge about leprosy increased and that negative attitudes reduced. The adjusted mean total score of the EMIC-CSS reduced by 4.95 points among respondents who had attended a contact event (n = 58; p <0.001, effect size = 0.75) compared to the score at baseline (n = 213); for the SDS this was 3.56 (p <0.001, effect size = 0.81). About 75% of those attending a contact event said they shared the information with others (median 10 persons). Conclusions/Significance: The contact intervention was effective in increasing knowledge and improving public attitudes regarding leprosy. It is relatively easy to replicate elsewhere and does not require expensive technology. More research is needed to improve scalability. The effectiveness of a contact intervention to reduce stigma against other neglected tropical diseases and conditions should be evaluated. [ABSTRACT FROM AUTHOR]

Background: The occurrence of adverse drug events (ADEs) during dapsone (DDS) treatment in patients with leprosy can constitute a significant barrier to the successful completion of the standardized therapeutic regimen for this disease. Well-known DDS-ADEs are hemolytic anemia, methemoglobinemia, hepatotoxicity, agranulocytosis, and hypersensitivity reactions. Identifying risk factors for ADEs before starting World Health Organization recommended standard multidrug therapy (WHO/MDT) can guide therapeutic planning for the patient. The objective of this study was to develop a predictive model for DDS-ADEs in patients with leprosy receiving standard WHO/MDT. Methodology: This is a case-control study that involved the review of medical records of adult (≥18 years) patients registered at a Leprosy Reference Center in Rio de Janeiro, Brazil. The cohort included individuals that received standard WHO/MDT between January 2000 to December 2021. A prediction nomogram was developed by means of multivariable logistic regression (LR) using variables. The Hosmer–Lemeshow test was used to determine the model fit. Odds ratios (ORs) and their respective 95% confidence intervals (CIs) were estimated. The predictive ability of the LRM was assessed by the area under the receiver operating characteristic curve (AUC). Results: A total of 329 medical records were assessed, comprising 120 cases and 209 controls. Based on the final LRM analysis, female sex (OR = 3.61; 95% CI: 2.03–6.59), multibacillary classification (OR = 2.5; 95% CI: 1.39–4.66), and higher education level (completed primary education) (OR = 1.97; 95% CI: 1.14–3.47) were considered factors to predict ADEs that caused standard WHO/MDT discontinuation. The prediction model developed had an AUC of 0.7208, that is 72% capable of predicting DDS-ADEs. Conclusion: We propose a clinical model that could become a helpful tool for physicians in predicting ADEs in DDS-treated leprosy patients. Author summary: Adverse events (AE) produced by the drugs used to treat leprosy can hinder the successful completion of the therapeutic regimen. Well-known AE produced by dapsone (DDS) are related to liver problems, allergic reactions, or to the destruction of red and/or white blood cells, causing anemia. Helping the physician to recognize a patient that may develop these adverse reactions can be useful. Thus, we developed a model to predict AE in patients with leprosy receiving standard World Health Organization-recommended multidrug therapy (WHO/MDT). Our question was whether we could use sociodemographic and clinical variables to generate a predictive model for DDS-ADEs. The model developed in this study could be a useful tool to assist physicians in predicting DDS-ADEs when treating patients with standard WHO/MDT for leprosy, and thus, establish a safer therapeutic plan for patients with a greater ADE risk. [ABSTRACT FROM AUTHOR]

Background: Prompt diagnosis and treatment of leprosy are crucial for preventing the disease's spread as well as for avoiding negative medical and social effects and reducing the disease's burden. The likelihood of nerve damage and subsequent disability rises as the length of the diagnostic delay. We aimed to explore the challenges of health professionals faced regarding their involvement in early leprosy case detection strategies. Methods: The study employed a qualitative, descriptive and phenomenological explorative research design to answer the research questions. By the use of non-probability purposive sampling, research participants were identified. During the study, in-depth interviews were conducted to gather information regarding the experiences of health workers (medical doctors, public health officers, clinical nurses, health centre heads and regional and Woreda district health office technical and programme experts) and health extension workers. To analyse the qualitative data, inductive thematic analysis techniques were used. For analysis, open code software version 4.0 was used. The data transcription, coding, display, reduction (theme) and interpretation of the discovered results were the processes undertaken for the analysis. Result: The findings of the study revealed that leprosy prevention and control programmes are still problematic. Themes that emerged from the data gleaned from the health workers included: lack of the existence of practice-oriented training, Integration of TB and leprosy training, lack of focus or other competing health priorities, Inadequate supportive supervision of health facilities, Multiple tasks for health workers, poor coordination and communications, lack of motivation in health workers, disruption in treatment, and Importance of training related to leprosy. Conclusion: Strengthening comprehensive leprosy training for health workers, carrying out efficient and thorough contact tracing, enhancing monitoring, supervision, assessment and surveillance, boosting managerial skills, lobbying political commitment, and motivating healthcare workers may help in early detection of leprosy cases strategies. Author summary: Leprosy is a chronic, infectious and contagious disease caused by the M. leprae bacterium. Skin lesions, loss of sensation, nerve damage, muscle weakness, and deformities are common characteristics of leprosy. Prompt diagnosis and treatment of leprosy are crucial for preventing the disease's spread as well as for avoiding negative medical and social effects and reducing the disease's burden. However the likelihood of nerve damage and subsequent disability rises as the length of the diagnostic delay increases. In this study, we identified that health professionals face many challenges to implement early detection of leprosy cases strategies like lack of the existence of practice-oriented training, Integration of TB and leprosy training, Inadequate supportive supervision of health facilities, Multiple tasks for health workers, Poor coordination and communications, lack of motivation in health workers, Disruption in treatment, and Importance of training related to leprosy outlined. The effective implementation of these strategies will be required for a sustainable reduction and achieve zero autochthonous cases and comply with the WHO's Leprosy Strategy by 2035. [ABSTRACT FROM AUTHOR]

Background: Bedaquiline (BDQ), by targeting the electron transport chain and having a long half-life, is a good candidate to simplify leprosy treatment. Our objectives were to (i) determine the minimal effective dose (MED) of BDQ administered orally, (ii) evaluate the benefit of combining two inhibitors of the respiratory chain, BDQ administered orally and clofazimine (CFZ)) and (iii) evaluate the benefit of an intramuscular injectable long-acting formulation of BDQ (intramuscular BDQ, BDQ-LA IM), in a murine model of leprosy. Methodology/Principal findings: To determine the MED of BDQ administered orally and the benefit of adding CFZ, 100 four-week-old female nude mice were inoculated in the footpads with 5x103 bacilli of M. leprae strain THAI53. Mice were randomly allocated into: 1 untreated group, 5 groups treated with BDQ administered orally (0.10 to 25 mg/kg), 3 groups treated with CFZ 20 mg/kg alone or combined with BDQ administered orally 0.10 or 0.33 mg/kg, and 1 group treated with rifampicin (RIF) 10 mg/kg. Mice were treated 5 days a week during 24 weeks. To evaluate the benefit of the BDQ-LA IM, 340 four-week-old female swiss mice were inoculated in the footpads with 5x103 to 5x101 bacilli (or 5x100 for the untreated control group) of M. leprae strain THAI53. Mice were randomly allocated into the following 11 groups treated with a single dose (SD) or 3 doses (3D) 24h after the inoculation: 1 untreated group, 2 treated with RIF 10 mg/kg SD or 3D, 8 treated with BDQ administered orally or BDQ-LA IM 2 or 20 mg/kg, SD or 3D. Twelve months later, mice were sacrificed and M. leprae bacilli enumerated in the footpad. All the footpads became negative with BDQ at 3.3 mg/kg. The MED of BDQ administered orally against M. leprae in this model is therefore 3.3 mg/kg. The combination of CFZ and BDQ 10-fold lower than this MED did not significantly increase the bactericidal activity of CFZ. The BDQ-LA IM displayed similar or lower bactericidal activity than the BDQ administered orally. Conclusion: We demonstrated that the MED of BDQ administered orally against M. leprae was 3.3 mg/kg in mice and BDQ did not add significantly to the efficacy of CFZ at the doses tested. BDQ-LA IM was similar or less active than BDQ administered orally at equivalent dosing and frequency but should be tested at higher dosing in order to reach equivalent exposure in further experiments. Author summary: The current multidrug therapy is effective against leprosy but remains long and difficult to observe for patients supporting the need of monthly -based treatment. Bedaquiline (BDQ), a diarylquinoline with a long half-life, is a candidate drug to shorten leprosy treatment by targeting the electron transport chain and inhibiting the ATP synthesis. In this work, we demonstrated that (i) the minimal effective dose of BDQ administered orally against M. leprae is 3.3 mg/kg, (ii) BDQ did not add significantly to the efficacy of CFZ at the doses tested, and (iii) BDQ long acting formulation was similar or less active than BDQ administered orally at equivalent dosing and frequency but should be tested at higher dosing in order to reach equivalent exposure in further experiments. [ABSTRACT FROM AUTHOR]

Background: Erythema Nodosum Leprosum (ENL) is a humoral immunological response in leprosy that leads to inflammatory skin nodules which may result in nerve and organ damage, and may occur years after antibiotic treatment. Multiple episodes are frequent and suppression requires high doses of immunosuppressive drugs. Global occurrence is unknown. Methodology/Principal Findings: Systematic review of evidence on ENL incidence resulted in 65 papers, predominantly from India (24) and Brazil (9), and inclusive of four reviews. Average incidences are based on cumulative incidence and size of study populations (n>100). In field-based studies 653/54,737 (1.2%) of all leprosy cases, 194/4,279 (4.5%) of MB cases, and 86/560 (15.4%) of LL cases develop ENL. Some studies found a range of 1–8 per 100 person-years-at-risk (PYAR) amongst MB cases. Hospital samples indicate that 2,393/17,513 (13.7%) of MB cases develop ENL. Regional differences could not be confirmed. Multiple ENL episodes occurred in 39 to 77% of ENL patients, with an average of 2.6. Some studies find a peak in ENL incidence in the first year of treatment, others during the second and third year after starting MDT. The main risk factor for ENL is a high bacteriological index. Conclusions/Significance: Few studies reported on ENL as a primary outcome, and definitions of ENL differed between studies. Although, in this review averages are presented, accurate data on global and regional ENL incidence is lacking. Large prospective studies or accurate surveillance data would be required to clarify this. Health staff needs to be aware of late reactions, as new ENL may develop as late as five years after MDT completion, and reoccurrences up to 8 years afterwards. Author Summary: This systematic review addresses an underpublicized and yet highly significant leprosy topic. Erythema Nodosum Leprosum (ENL) is a serious complication in multi-bacillary (MB) leprosy that may lead to severe disability. Inflammatory skin nodules may result in nerve and organ damage and require high doses of immunosuppressive drugs. ENL can occur long after patients are released from antibiotic treatment. Frequency and severity of ENL is unknown; this review confirms the lack of accurate data at global, regional, and national levels. Available data indicates that ENL incidence ranges between 0.7–4.6% of all MB cases and late reoccurrence up to 8 years after release from treatment. ENL episodes often reoccur, with an average of 2.6 times. The main risk factor for ENL is a high bacteriological index. Additionally, data indicate a wide variation of ENL occurrence between and within countries. The conclusions demonstrate the need for increased awareness about ENL, in research, patient surveillance, and in programme management. [ABSTRACT FROM AUTHOR]

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. Author summary: Our review summarizes the clinical and epidemiological characteristics of non-viral co-infections in leprosy patients, including tuberculosis, leishmaniasis, chromoblastomycosis, and helminths. By conducting a systematic literature search, my colleagues and I identified 89 studies and found a male-dominated pattern of co-infections among working-age individuals with multibacillary leprosy. Our findings suggest that co-infections with tuberculosis and leishmaniasis may reduce the occurrence of leprosy reactions, which is in contrast to prior studies reporting increased reactions in chronic viral co-infections. Additionally, we observed that the occurrence of leprosy reactions varied from 37% to 81% across studies, depending on the type of helminth co-infection, which is higher than the general population. Overall, our study highlights the importance of understanding the potential impact of co-infections on leprosy patients, as it may affect their disease outcomes and treatment. This information is relevant not only to researchers and healthcare providers but also to the general public, as leprosy is still a significant public health problem in many parts of the world. Our review adds to the growing body of knowledge in the field of infectious diseases and underscores the need for further research on this topic. [ABSTRACT FROM AUTHOR]

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 Author summary: Leprosy is a chronic, granulomatous disease caused by Mycobacterium leprae and is a major cause of preventable disability. As a result of their disfigurements and deteriorating physical impairments, the leprosy-affected individuals experienced negative social attitudes, stigma, isolation, and discrimination, thus, impacting their lives and relationships with others. Due to the chronicity of leprosy, studying the lived experience of the affected individuals will allow us a deeper understanding of the effects of the disease, how they seek help and adhere to its treatment, and cope with the disease. We conducted a systematic literature review involving 49 articles, highlighting the four synthesised findings: biophysical impact, social impact, economic impact, and mental and emotional impact. These synthesised findings were not new, but they were consistent across the included studies from a patient's perspective. Our findings contributed to establishing the biopsychosocial and economic approach for understanding what leprosy-affected people experience by considering changes in their biophysical, sociocultural, psychological dynamics, and economics. It served as a guide for delivering care and treatment to these people. The information will be helpful to the researchers, health professionals, decision, and policymakers to plan and tailor their support for these individuals, their families, and the community. [ABSTRACT FROM AUTHOR]

Background: Family involvement in overcoming the severity of leprosy is very important in the life of leprosy sufferers in communities who experience the clinical and, psychological, social and behavioral consequences of the disease. However, this need, psychosocial, is felt to be not optimal. This study is to identify how the experiences of family members as caregivers provide assistance to lepers in improving healing and maintaining patterns of interaction in the family. Methods: The design uses qualitative research with in-depth, face-to-face interviews with family members in a semi-structured manner with the hope of obtaining complete data. Using purposive sampling with Participatory Interpretative Phenomenology analysis, there are 12 families with 15 family members consisting of 4 men and 11 women. Results: This study produced a family theme that tried to follow what would happen to lepers, with four sub-categories: 1) Using various coping alternatives to recognize the disease, 2) Family members in the shadow of leprosy, 3) Trying to empathize with other family members. sick, 4) Caring for the emotional response of the family and seeking support. Conclusions: This analysis shows that deficiency in cognitive aspects can be closed by maintaining a lifestyle in the family through efforts to understand, support, establish communication, increase maximum involvement in restoring self-confidence, especially in lepers with psychosocial problems in the family. The results of this study can be used as psychosocial support in maintaining communication between family members to support treatment programs and accelerate the recovery of leprosy. Author summary: Although families have high empathy for the physical, psychological, and social problems faced by lepers, they are rarely involved in the personal affairs of lepers, and there are indications that they left them to cure their disease. Meanwhile, overcoming problems in their own way without involving other family members, becomes the main choice for people with leprosy to avoid conflicts between family members, because they realize that leprosy is a disgrace in their family. However, the interaction between family members is an Indonesian culture that continues to be preserved. And for whatever reason, the culture of interaction between family members cannot be abandoned, even though there are obstacles that must be faced because this is a tool to strengthen kinship. The writer found that the family tried to help in healing leprosy suffered by their family members, even though they were in the shadow of leprosy. Through various coping strategies implemented, families try to help the healing process of their illness, with the hope that they will rise from adversity and have high motivation to recover. And restoring the confidence of people with leprosy is important to support a definitive treatment program. [ABSTRACT FROM AUTHOR]

Background: HIV infection is highly prevalent in French Guiana, a territory where leprosy is also endemic. Since the introduction of Highly Active Antiretroviral Treatment (HAART) in the management of HIV, leprosy has been reported as part of the immune reconstitution inflammatory syndrome (IRIS). Methodology/Principal findings: We aimed to present a general description of these forms of leprosy as IRIS, highlighting clinical and therapeutic specificities. A retrospective study was conducted in French Guiana, including patients living with HIV (PLHIV) with advanced infection (CD4 < 200/mm3) and developing leprosy or a leprosy reaction within six months of HAART initiation, from 2000 to 2020. Clinical, histological and biological data were collected for all these patients. Six patients were reported in French Guiana. A systematic review of the literature was conducted, and its results were added to an overall analysis. Overall, seventy-three PLHIV were included. They were mainly men (74%), aged 22–54 years (median 36 years), mainly from Brazil (46.5%) and India (32.8%). Most leprosy cases (56.2%) were borderline tuberculoid (BT). Leprosy reactions were frequent (74%), mainly type 1 reaction (T1R) (68.5%), sometimes intense with ulceration of skin lesions (22%). Neuritis was observed in 30.1% of patients. The outcome was always favorable under multidrug therapy (MDT), continuation of HAART and additional corticosteroid therapy in case of neuritis or ulceration. There was no relapse. Conclusion: Leprosy as IRIS in PLHIV mainly presents as a BT leprosy in a T1R state, sometimes with ulcerated skin lesions. Response to MDT is usually good. Systemic corticosteroids are necessary and efficient in case of neuritis. Author summary: Leprosy is an infection caused by Mycobacterium leprae characterized by skin and nerve lesions. Leprosy reactions can be observed, depending on variations in host-specific cellular immunity. Leprosy is described after antiretroviral therapy (HAART) initiation in immunocompromised PLHIV from countries where leprosy and HIV infections are endemic. This is known as immune restoration inflammatory syndrome (IRIS), a brutal inflammatory response directed against a latent or quiescent pathogen. In this study we searched for cases of leprosy as IRIS in French Guiana and those published in the literature in order to describe their clinical characteristics. Overall, our results show that these cases are mostly observed as borderline tuberculoid leprosy, associated with or quickly followed by a type 1 leprosy reaction, sometimes with neuritis and/or ulceration of lesions. The outcome is favorable under standard leprosy treatment with HAART maintenance. [ABSTRACT FROM AUTHOR]

Background: Lower limb disorders including lymphoedema create a huge burden for affected persons in their physical and mental health, as well as socioeconomic and psychosocial consequences for them, their families and communities. As routine health services for the integrated management and prevention of lower limb disorders are still lacking, the 'Excellence in Disability Prevention Integrated across Neglected Tropical Diseases' (EnDPoINT) study was implemented to assess the development and delivery of an integrated package of holistic care–including physical health, mental health and psychosocial care–within routine health services for persons with lower limb disorders caused by podoconiosis, lymphatic filariasis and leprosy. Methodology/Principal findings: This study was part of the first of three phases within EnDPoINT, involving the development of the integrated care package. Focus group discussions and key informant interviews were undertaken with 34 participants between January–February 2019 in Awi zone, Ethiopia, in order to assess the draft care package's feasibility, acceptability and appropriateness. Persons affected by lower limb disorders such as lymphoedema experience stigma, exclusion from families, communities and work as well as physical and financial hardship. Beliefs in disease causation inhibit affected persons from accessing care. Ignorance was a barrier for health care providers as well as affected persons. Training and education of affected persons, communities and caregivers is important in improving care access. It also requires time, space, materials and financial resources. Both top-down and grass roots input into service development are key, as well as collaboration across stakeholders including charities, community leaders and "expert patients". Conclusions/Significance: This study highlighted the need for the EnDPoINT integrated care package and provided suggestions for solutions according to its three aspects of integrated care (integration into routine care; integration of mental health and psychosocial care; and integration of care across the three diseases), thereby giving support for its feasibility, acceptability and appropriateness. Author summary: Lower limb disorders including lymphoedema are prevalent in Ethiopia as a common endpoint of varying causes such as podoconiosis, leprosy and lymphatic filariasis. This study involved the development of a comprehensive integrated and holistic care package for lower limb disorders into routine health care services. It used interviews and focus groups to assess feasibility, acceptability and appropriateness of the draft care package. We found that persons affected by lower limb disorders had many negative experiences due to their condition, especially related to stigma, that included physical, financial and psychological sequelae. Neglect was paramount, with financial neglect in central budgets, a lack of knowledge by care givers and a lack of awareness among affected persons and their communities, all contributing to inadequate care provision and access. Affected persons, communities and caregivers may benefit from provision of learning opportunities about the prevention and treatment of lower limb disorders; and resources are crucial in engendering change, including material goods, time to provide care, and collaborative work to create a culture shift and address stigma. [ABSTRACT FROM AUTHOR]

Background: Leprosy is a chronic infectious disease caused by Mycobacterium leprae, the annual new case detection in 2019 was 202,189 globally. Measuring endemicity levels and burden in leprosy lacks a uniform approach. As a result, the assessment of leprosy endemicity or burden are not comparable over time and across countries and regions. This can make program planning and evaluation difficult. This study aims to identify relevant metrics and methods for measuring and classifying leprosy endemicity and burden at (sub)national level. Methods: We used a mixed-method approach combining findings from a systematic literature review and a Delphi survey. The literature search was conducted in seven databases, searching for endemicity, burden and leprosy. We reviewed the available evidence on the usage of indicators, classification levels, and scoring methods to measure and classify endemicity and burden. A two round Delphi survey was conducted to ask experts to rank and weigh indicators, classification levels, and scoring methods. Results: The literature review showed variation of indicators, levels, and cut-off values to measure leprosy endemicity and/or burden. The most used indicators for endemicity include new case detection rate (NCDR), new cases among children and new cases with grade 2 disability. For burden these include NCDR, MB cases, and prevalence. The classification levels 'high' and 'low' were most important. It was considered most relevant to use separate scoring methods for endemicity and burden. The scores would be derived by use of multiple indicators. Conclusion: There is great variation in the existing method for measuring endemicity and burden across countries and regions. Our findings contribute to establishing a standardized uniform approach to measure and classify leprosy endemicity and burden at (sub)national level, which would allow effective communication and planning of intervention strategies. Author summary: Leprosy is a chronic infectious disease caused by Mycobacterium leprae. If left untreated, it could lead to deformity and resultant disabilities. The number of new cases has remained stagnant for the past decade. Additional interventions are required tailored to the level of endemicity and burden of an area. Currently, measuring and classifying endemicity and burden in leprosy lacks a standardized uniform approach, making program planning and evaluation difficult. We did a systematic literature search and Delphi survey, a method to elicit (group) opinion from a panel of experts, to take an inventory of indicators, classification levels and cut-offs that were used to measure and classify endemicity and burden of leprosy. This study highlights the variation in usage of indicators, levels, and cut-off values to determine the endemicity and burden of leprosy across regions and countries. There was agreement that endemicity and burden should be measured separately using multiple indicators, and that the classification levels 'high' and 'low' were most important. Our findings contribute to establishing a standardized uniform approach to measure and classify leprosy endemicity and burden at (sub)national level, which would allow effective communication and planning of intervention strategies. [ABSTRACT FROM AUTHOR]

Introduction: Since ancient times leprosy has had a negative perception, resulting in stigmatization. To improve the lives of persons affected by leprosy, these negative perceptions need to change. The aim of this study is to evaluate interventions to change perceptions and improve knowledge of leprosy. Methodology/Principal findings: We conducted a pre-post intervention study in Fatehpur and Chandauli districts, Uttar Pradesh, India. Based on six steps of quality intervention development (6SQuID) two interventions were designed: (1) posters that provided information about leprosy and challenged misconceptions, and (2) meetings with persons affected by leprosy, community members and influential people in the community. The effect of the interventions was evaluated in a mixed-methods design; in-depth interviews, focus group discussions, and questionnaires containing a knowledge measure (KAP), two perception measures (EMIC-CSS, SDS) and an intervention evaluation tool. 1067 participants were included in Survey 1 and 843 in Survey 2. The interventions were effective in increasing knowledge of all participant groups, and in changing community and personal attitudes of close contacts and community members (changes of 19%, 24% and 13% on the maximum KAP, EMIC-CSS and SDS scores respectively, p<0.05). In Survey 1, 13% of participants had adequate knowledge of leprosy versus 53% in Survey 2. Responses showed stigmatizing community attitudes in 86% (Survey 1) and 61% (Survey 2) of participants and negative personal attitudes in 37% (Survey 1) and 19% (Survey 2). The number of posters seen was associated with KAP, EMIC-CSS and SDS scores in Survey 2 (p<0.001). In addition, during eight post-intervention focus group discussions and 48 interviews many participants indicated that the perception of leprosy in the community had changed. Conclusions/Significance: Contextualized posters and community meetings were effective in changing the perception of leprosy and in increasing leprosy-related knowledge. We recommend studying the long-term effect of the interventions, also on behavior. Author summary: To improve the lives of persons with leprosy, perceptions about leprosy need to change. The aim of this study is to describe the development and evaluation of interventions (posters and community meetings) to change the perception and improve knowledge of leprosy in Fatehpur and Chandauli districts, India. To measure the effect of the interventions we administered questionnaires before and after the interventions and we conducted 48 interviews and eight group interviews afterwards. In total 1067 participants were included in the first survey and 843 in the second. We found that the interventions resulted in more knowledge of leprosy and in changed community and personal attitudes towards (persons affected by) leprosy. The percentage of participants with adequate knowledge of leprosy was higher in the second survey and the percentage of participants with negative community and personal attitudes was lower. In the interviews, many participants indicated that there had been a change in perception in the community. The more posters participants had seen, the better their knowledge of leprosy and the more positive their attitudes. Findings from this study suggest that contextualized posters and community meetings can be effective in changing the perception of leprosy and increasing leprosy-related knowledge. [ABSTRACT FROM AUTHOR]

Background: Regarding the leprosy transmission through the upper airways, overcrowded locations such as prisons can become a risk to get sick. Like the leprosy hidden endemic demonstrated in male prison population, being interesting to assess the leprosy scene also among confined women. Methods: A prospective descriptive study conducted at Female Penitentiary, Brazil. Leprosy Suspicion Questionnaire (LSQ) were applied to the participants, and submitted to specialized dermatoneurological exam, peripheral nerve ultrasonography, and anti-PGL-I serology. Findings: 404 female inmates were evaluated, 14 new cases were diagnosed (LG-leprosy group), a new case detection rate (NCDR) of 3.4%, 13 multibacillary, while another 390 constituted the Non-Leprosy group (NLG). Leprosy cases were followed up during multidrug therapy with clinical improvement. The confinement time median was 31 months in LG, similar to NLG, less than the time of leprosy incubation. Regarding LSQ, the neurological symptoms reached the highest x2 values as Q1–numbness (5.6), Q3–anesthetizes areas in the skin (7.5), Q5–Stinging sensation (5.8), and Q7–pain in the nerves (34.7), while Q4-spots on the skin was 4.94. When more than one question were marked in the LSQ means a 12.8-fold higher to have the disease than a subject who marked only one or none. The high 34% rate of anti-PGL-I seropositivity in the penitentiary, higher levels in LG than NLG. Three additional leprosy cases each were diagnosed on the second (n = 66) and third (n = 14) reevaluations 18 and 36 months after the initial one. Semmes-Weinstein monofilaments demonstrated lower limbs (32.2%) more affected than the upper limbs (25%) with improvement during the follow-up. Interpretation: The NCDR in this population showed an hidden endemic of leprosy as well as the efficacy of a search action on the part of a specialized team with the aid of the LSQ and anti-PGL-I serology as an auxiliary tracking tools. Author summary: The study was conducted in a Female Penitentiary-Brazil. The Leprosy Suspicion Questionnaire (LSQ) was administered to all the inmates who also underwent, specialized dermato-neurological exam, and anti-PGL-I serology. We evaluated 404 female inmates, 14 new cases were diagnosed (LG-leprosy group), and 390 constituted the Non-Leprosy group (NLG), a new case detection rate of 3.4%. The confinement time was shorter than the time of leprosy incubation. Leprosy cases were followed up during multidrug therapy and it showed clinical improvement. Regarding the LSQ, the most important neurological symptoms were Q1–numbness, Q3–anesthetized areas, Q5–Stinging sensation, and Q7–pain in the nerves, while Q4-spots were fewer. When more than one question was marked, it meant a 12.8 higher chance to get leprosy. The high anti-PGL-I seropositivity among females was higher in the LG than in the NLG. Afterwards, we reevaluated the inmates and 6 additional leprosy cases were diagnosed in two visits. Semmes-Weinstein monofilaments demonstrated that the lower limbs (32.2%) were more affected than the upper limbs (25%) with improvement during the follow-up. Thus, our study in this population showed hidden leprosy as in the male prison. It also showed how efficient the search by a specialized staff with the aid of LSQ, as an auxiliary tracking tool, is. [ABSTRACT FROM AUTHOR]

Background: Crusted scabies is endemic in some remote Aboriginal communities in the Northern Territory (NT) of Australia and carries a high mortality risk. Improvement in active case detection (ACD) for crusted scabies is hampered by a lack of evidence about best practice. We therefore conducted a systematic review of ACD methods for leprosy, a condition with similar ACD requirements, to consider how findings could be informative to crusted scabies detection. Methods and principle findings: We conducted systematic searches in MEDLINE, CINAHL, Scopus and the Cochrane Database for Systematic Reviews for studies published since 1999 that reported at least one comparison rate (detection or prevalence rate) against which the yield of the ACD method could be assessed. The search yielded 15 eligible studies from 511. Study heterogeneity precluded meta-analysis. Contact tracing and community screening of marginalised ethnic groups yielded the highest new case detection rates. Rapid community screening campaigns, and those using less experienced screening personnel, were associated with lower suspect confirmation rates. There is insufficient data to assess whether ACD campaigns improve treatment outcomes or disease control. Conclusion: This review demonstrates the importance of ACD campaigns in communities facing the highest barriers to healthcare access and within neighbourhoods of index cases. The potential benefit of ACD for crusted scabies is not quantified, however, lessons from leprosy suggest value in follow-up with previously identified cases and their close contacts to support for scabies control and to reduce the likelihood of reinfection in the crusted scabies case. Skilled screening personnel and appropriate community engagement strategies are needed to maximise screening uptake. More research is needed to assess ACD cost effectiveness, impact on disease control, and to explore ACD methods capable of capturing the homeless and highly mobile who may be missed in household centric models. Author summary: Crusted scabies is a severely debilitating skin disease with potentially fatal consequences that is endemic in some remote Aboriginal communities in the Northern Territory (NT) of Australia. Early detection is essential to maximise the chance of recovery and help prevent transmission of scabies to others. There is little knowledge about how to actively detect crusted scabies, so we sought relevant knowledge about a disease with many similarities: leprosy. The review demonstrates the importance of ACD campaigns in communities facing the highest barriers to healthcare access and within neighbourhoods of index cases. Lessons for crusted scabies in the NT include the importance of skilled screening personnel and appropriate community engagement strategies to maximise screening uptake. More research is needed to assess ACD cost effectiveness, impact on disease control, and to explore ACD methods capable of capturing the homeless and highly mobile who may be missed in household centric models. [ABSTRACT FROM AUTHOR]

The World Health Organization has raised concerns about the increasing number of Hansen disease (HD) relapses worldwide, especially in Brazil, India, and Indonesia that report the highest number of recurrent cases. Relapses are an indicator of MDT effectiveness and can reflect Mycobacterium leprae persistence or re-infection. Relapse is also a potential marker for the development or progression of disability. In this research, we studied a large cohort of persons affected by HD treated with full fixed-dose multibacillary (MB) multidrug therapy (MDT) followed for up to 20 years and observed that relapses are a rare event. We estimated the incidence density of relapse in a cohort of patients classified to receive MB regime (bacillary index (BI) > 0), diagnosed between September 1997 and June 2017, and treated with twelve-dose MB-MDT at a HD reference center in Rio de Janeiro, Brazil. We obtained the data from the data management system of the clinic routine service. We linked the selected cases to the dataset of relapses of the national HD data to confirm possible relapse cases diagnosed elsewhere. We diagnosed ten cases of relapse in a cohort of 713 patients followed-up for a mean of 12.1 years. This resulted in an incidence rate of 1.16 relapse cases per 1000 person-year (95% CI = 0.5915–2.076). The accumulated risk was 0.025 in 20 years. The very low risk observed in this cohort of twelve-dose-treated MB patients reinforces the success of the current MDT scheme. Author summary: People affected by Hansen disease that have many skin patches or lumps receive twelve-dose multibacillary multidrug therapy. After the fixed-dose regime, they are released from treatment and are considered cured. However, some of these people may have a recurrence of skin lesions or peripheral nerve problems after several years. Clinicians, scientists, and the World Health Organization are concerned about this problem, known as relapse, which seems to be increasing in countries where Hansen disease is common, especially in Brazil, India, and Indonesia. It is important to demonstrate regular proof that the therapy remains effective to treat people affected by Hansen disease. In this study, we showed that the recurrence of signs and symptoms of Hansen disease after the twelve-dose multibacillary treatment is rare. These findings are good evidence of the success of the current multibacillary scheme. [ABSTRACT FROM AUTHOR]

Background: This study reviews the progress of leprosy elimination in Yunnan, China, over the past 30 years and identifies the challenges for the next stage of the program. Methodology/Principal findings: Data were collected from the Leprosy Management Information System in China (LEPMIS). The progress made in the elimination of leprosy between 1990 and 2019 was measured. We defined two time periods, time period 1 (1990–2003) and time period 2 (2004–2019), because multidrug therapy (MDT) was launched for the treatment of leprosy in 1990 and a special fund from the central government was established for leprosy in 2004. During the past 30 years, the number of newly detected leprosy patients in Yunnan has steadily declined. In total, 703 newly detected leprosy patients were reported in 1990, and 353 and 136 cases were reported at the end of 2003 and 2019, respectively. At the end of 1990, 90.7% (117/129) of counties in Yunnan Province were identified as leprosy-endemic counties (>1 case per 100,000 population). By the end of 2003 and 2019, 39.3% (46/117) and 85.5% (100/117) of the leprosy-endemic counties, respectively, had dropped below the elimination threshold. The main challenges are the remaining leprosy-endemic counties, the high rate of cases with a contact history, insufficient early detection, and leprosy cases resulting in physical disability. Conclusions/Significance: A multifaceted strategy for leprosy elimination in Yunnan Province has been successfully implemented, and remarkable progress has been made in the elimination of leprosy in this area. The priorities for leprosy elimination in the next stage are securing sustainable support and investment from the government, establishing an effective surveillance system, ensuring prompt early detection, providing treatment with MDT, preventing transmission of M. leprae, preventing disability, providing health education, and preventing recurrence of the epidemic situation of leprosy. Author summary: Compared to other provinces in China, Yunnan bears a significant burden of leprosy disease. Multidrug therapy (MDT) was launched for leprosy in 1990, and a special fund for leprosy was established in Yunnan Province by the central government in 2004. During the past 30 years, the number of newly detected leprosy patients has steadily declined, accompanied by an enormous decrease in the number of leprosy-endemic regions. Compared to the 1990–2003 period, the period after the establishment of the special fund from the central government (2004–2019) saw a decrease in the proportion of child cases and patients with grade 2 disability (G2D) and in the duration of delay in diagnosis among newly detected patients, while the proportion of patients with paucibacillary (PB) leprosy, the proportion belonging to minority groups, and the proportion of cases detected early increased significantly. The main challenges are the remaining leprosy-endemic counties, the high rate of cases with a contact history, insufficient early detection, and cases resulting in G2D. To eliminate leprosy in Yunnan Province, a multifaceted strategy should be implemented. [ABSTRACT FROM AUTHOR]

A key issue for persons with leprosy-, lymphatic filariasis- and podoconiosis-related disabilities is the life-long need to practice self-management routines. This is difficult to sustain without regular encouragement and support of others. Family-based support may be a sustainable and feasible strategy to practice self-management routines. This proof of concept study aimed to develop and pilot a family-based intervention to support prevention and self-management of leprosy, lymphatic filariasis and podoconiosis-related disabilities in Ethiopia. We used a quasi-experimental pre/post intervention study design with a mixed methods approach. The study population included persons affected by leprosy, lymphatic filariasis and podoconiosis and their family members. All persons affected had visible impairments due to their condition. We collected physical impairment outcomes, data on activity limitations, stigma and family quality of life using the SALSA scale (range 0–80), the SARI stigma scale (range 0–63) and the Beach Centre Family Quality of Life scale (range 0–125) and conducted in-depth interviews and focus group discussions. Quantitative data were analysed using paired t-tests, unequal variances t-tests, linear regression and binary logistic regression. Qualitative data were coded using open, inductive coding and content analysis. The family-based intervention consisted of self-management of disabilities, awareness raising and socio-economic empowerment. The intervention was delivered over several monthly group meetings over the course of several months. A total of 275 (100%) persons affected attended at least one session with a family member, and 215 (78%) attended at least three sessions. There was no significant improvement in eye and hand problems after the intervention. However, foot and leg impairments, number of acute attacks, lymphedema and shoe wearing all significantly improved at follow-up. In addition, family quality of life significantly improved from 67.4 at baseline to 89.9 at follow-up for family members and from 76.9 to 84.1 for persons affected (p<0.001). Stigma levels significantly decreased from 24.0 at baseline to 16.7 at follow-up (p<0.001). Activity levels improved, but not significantly. This proof of concept study showed that the family-based intervention had a positive effect on impairments and self-management of disabilities, family quality of life and stigma. We recommend a large-scale efficacy trial, using a randomised controlled trial and validated measurement tools, to determine its effectiveness and long-term sustainability. Author summary: A key issue for persons with leprosy-, lymphatic filariasis- and podoconiosis-related disabilities is the life-long need to practice self-management routines. Family-based support may be a sustainable and feasible strategy to practice self-management. This proof of concept study aimed to develop and pilot a family-based intervention to support prevention and self-management of leprosy, lymphatic filariasis and podoconiosis-related disabilities in Ethiopia. We collected data on physical impairments, activity limitations, stigma and family quality of life, and conducted in-depth interviews and focus group discussions. The family-based intervention consisted of self-management of disabilities, awareness raising and socio-economic empowerment. The intervention was delivered over several monthly group meetings. A total of 275 persons affected attended at least one session with a family member. There was no significant improvement in eye and hand problems after the intervention. However, foot and leg impairments, number of acute attacks, lymphedema and shoe wearing all significantly improved. In addition, family quality of life significantly improved, and stigma levels significantly decreased after the intervention. Activity levels improved, but not significantly. This proof of concept study showed that the family-based intervention had a positive effect on impairments and self-management of disabilities, family quality of life and stigma. [ABSTRACT FROM AUTHOR]

Background: Understanding how knowledge, attitudes and practices regarding leprosy differ in endemic countries can help us develop targeted educational and behavioural change interventions. This study aimed to examine the differences and commonalities in and determinants of knowledge, attitudes, practices and fears regarding leprosy in endemic districts in India and Indonesia. Principle findings: A cross-sectional mixed-methods design was used. Persons affected by leprosy, their close contacts, community members and health workers were included. Through interview-administered questionnaires we assessed knowledge, attitudes, practices and fears with the KAP measure, EMIC-CSS and SDS. In addition, semi-structured interviews and focus group discussions were conducted. The quantitative data were analysed using stepwise multivariate regression. Determinants of knowledge and stigma that were examined included age, gender, participant type, education, occupation, knowing someone affected by leprosy and district. The qualitative data were analysed using open, inductive coding and content analysis. We administered questionnaires to 2344 participants (46% from India, 54% from Indonesia) as an interview. In addition, 110 participants were interviewed in-depth and 60 participants were included in focus group discussions. Knowledge levels were low in both countries: 88% of the participants in India and 90% of the participants in Indonesia had inadequate knowledge of leprosy. In both countries, cause, mode of transmission, early symptoms and contagiousness of leprosy was least known, and treatment and treatability of leprosy was best known. In both countries, health workers had the highest leprosy knowledge levels and community members the highest stigma levels (a mean score of up to 17.4 on the EMIC-CSS and 9.1 on the SDS). Data from the interviews indicated that people were afraid of being infected by leprosy. Local beliefs and misconceptions differed, for instance that leprosy is in the family for seven generations (Indonesia) or that leprosy is a result of karma (India). The determinants of leprosy knowledge and stigma explained 10–29% of the variability in level of knowledge and 3–10% of the variability in level of stigma. Conclusion: Our findings show the importance of investigating the perceptions regarding leprosy prior to educational interventions in communities: even though knowledge levels were similar, local beliefs and misconceptions differed per setting. The potential determinants we included in our study explained very little of the variability in level of knowledge and stigma and should be explored further. Detailed knowledge of local knowledge gaps, beliefs and fears can help tailor health education to local circumstances. Author summary: This study aimed to examine the differences and commonalities in and determinants of knowledge, attitudes, practices and fears regarding leprosy in endemic districts in India and Indonesia. Persons affected by leprosy, their close contacts, community members and health workers were included. We administered questionnaires (the KAP measure, EMIC-CSS and SDS) to 2344 participants. In addition, 110 participants were interviewed in-depth and 60 participants were included in focus group discussions. Knowledge levels were low. In both countries, cause, mode of transmission, early symptoms and contagiousness of leprosy was least known, and treatment and treatability of leprosy was best known. In both countries, health workers had the highest leprosy knowledge levels and community members the highest stigma levels. Data from the interviews indicated that people were afraid of being infected by leprosy. Local beliefs and misconceptions differed. The potential determinants we included in our study explained very little of the variability in level of knowledge and stigma and should be explored further. Our findings show the importance of investigating the perceptions regarding leprosy prior to educational interventions in communities: even though knowledge levels were similar, local beliefs and misconceptions differed per setting. [ABSTRACT FROM AUTHOR]

Background: This study evaluates an active search strategy for leprosy diagnosis based on responses to a Leprosy Suspicion Questionnaire (LSQ), and analyzing the clinical, immunoepidemiological and follow-up aspects for individuals living in a prison population. Methods: A cross-sectional study based on a questionnaire posing 14 questions about leprosy symptoms and signs that was distributed to 1,400 prisoners. This was followed by dermatoneurological examination, anti-PGL-I serology and RLEP-PCR. Those without leprosy were placed in the Non-leprosy Group (NLG, n = 1,216) and those diagnosed with clinical symptoms of leprosy were placed in the Leprosy Group (LG, n = 34). Findings: In total, 896 LSQ were returned (64%), and 187 (20.9%) of the responses were deemed as positive for signs/symptoms, answering 2.7 questions on average. Clinically, 1,250 (89.3%) of the prisoners were evaluated resulting in the diagnosis of 34 new cases (LG), based on well-accepted clinical signs and symptoms, a new case detection rate of 2.7% within this population, while the NLG were comprised of 1,216 individuals. The confinement time medians were 39 months in the LG while it was 36 months in the NLG (p>0.05). The 31 leprosy cases who responded to the questionnaire (LSQ+) had an average of 1.5 responses. The symptoms "anesthetized skin area" and "pain in nerves" were most commonly mentioned in the LG while "tingling, numbness in the hands/feet", "sensation of pricks and needles", "pain in nerves" and "spots on the skin" responses were found in more than 30% of questionnaires in the NLG. Clinically, 88.2% had dysesthetic macular skin lesions and 97.1% presented some peripheral nerve impairment, 71.9% with some degree of disability. All cases were multibacillary, confirming a late diagnosis. Anti-PGL-I results in the LG were higher than in the NLG (p<0.0001), while the RLEP-PCR was positive in 11.8% of the patients. Interpretation: Our findings within the penitentiary demonstrated a hidden prevalence of leprosy, although the individuals diagnosed were likely infected while living in their former communities and not as a result of exposure in the prison. The LSQ proved to be an important screening tool to help identify leprosy cases in prisons. Author summary: Leprosy looms still as a public health problem. Unfortunately, the drop in the number of leprosy cases in recent decades has been accompanied by general decline in the expertise of health care professionals to recognize signs and symptoms of leprosy, particularly at the early stages. The situation for individuals confined within a prison is likely worse because it would be rare for this population to receive a clinical exam for leprosy even in the case of obvious signs and symptoms. In this study, we used an active search strategy in the prison population providing them a Leprosy Suspicion Questionnaire (LSQ) with 14 simple questions about symptoms and signs related to leprosy. This questionnaire proved to be a simple, low-cost instrument for screening and identifying new leprosy cases among 1,400 prisoners. After responding to the questionnaire, they were evaluated clinically, and samples of blood and earlobe skin smears were collected for later laboratory anti-PGL-I IgM and RLEP-PCR assessment. Neurological symptoms ("anesthetized skin area" and "pain in nerves) were more commonly associated among the 34 new multibacillary cases diagnosed at penitentiary (rate 2.7%). The confinement time among leprosy patients (LG) was slightly longer than time of leprosy incubation indicating that the infection likely occurred before the imprisonment. Anti-PGL-I results in the LG were higher than in non-leprosy group and RLEP-PCR was positive in 11.8% of the patients, demonstrating that this disease is actually present in the confinement community. The application of the LSQ coupled with follow-up clinical exams and laboratory analysis are all actions with a high potential to reveal new leprosy cases in these confined communities. [ABSTRACT FROM AUTHOR]

Background: Leprosy transmission is ongoing; globally and within Bangladesh. Household contacts of leprosy cases are at increased risk of leprosy development. Identification of household contacts at highest risk would optimize this process. Methods: The temporal pattern of new case presentation amongst household contacts was documented in the COCOA (Contact Cohort Analysis) study. The COCOA study actively examined household contacts of confirmed leprosy index cases identified in 1995, and 2000–2014, to provide evidence for timings of contact examination policies. Data was available on 9527 index cases and 38303 household contacts. 666 household contacts were diagnosed with leprosy throughout the follow-up (maximum follow-up of 21 years). Risk factors for leprosy development within the data analysed, were identified using Cox proportional hazard regression. Findings: The dominant risk factor for household contacts developing leprosy was having a highly skin smear positive index case in the household. As the grading of initial slit skin smear of the index case increased from negative to high positive (4–6), the hazard of their associated household contacts developing leprosy increases by 3.14 times (p<0.001). Being a blood relative was not a risk factor, no gender differences in susceptibility were found. Interpretation: We found a dominance of a single variable predicting risk for leprosy transmission–skin smear positive index cases. A small number of cases are maintaining transmission in the household setting. Focus should be performing contact examinations on these households and detecting new skin smear positive index cases. Conducting slit-skin smears on new cases is needed for predicting risk; such services need supporting. If skin smear positive cases are sustaining leprosy infection within the household setting, the administration of single-dose rifampicin (SDR) to household contacts as the sole intervention in Bangladesh will not be effective. Author summary: The number of newly detected leprosy cases worldwide has remained stable over the last ten years. Household contacts of leprosy cases are at increased risk of leprosy development. Household contact examinations and case detection are critical aspects of control. Specific risk factors (recognizable by field staff) for leprosy development need to be identified to aid these control efforts. Targeted household examinations could increase early case detection: this is important because untreated leprosy cases are sustaining transmission. This is the largest, most comprehensive study of development of leprosy in household contacts conducted recently with a maximum follow-up of 21 years. We found a single dominant risk factor for the development of leprosy in the household setting, namely slit skin smear positivity in the index case. This is important for leprosy control because household contact examinations can be focused on contacts at highest risk. Implementation would be simple as the risk factor is identified by leprosy staff in the field. Prioritising households known to be at highest risk of leprosy development would allow efficient allocation of resources. Our results cast doubt on the success of administering the recommended prophylactic intervention for contacts; the use of this intervention needs to be re-evaluated. [ABSTRACT FROM AUTHOR]

India has the highest burden of leprosy in the world. Following a recent WHO guideline, the Indian National Leprosy Programme is introducing post-exposure prophylaxis with single-dose rifampicin (SDR-PEP) in all high-endemic districts of the country. The aim of this study is to estimate the long-term cost-effectiveness of SDR-PEP in different leprosy disability burden situations. We used a stochastic individual-based model (SIMCOLEP) to simulate the leprosy new case detection rate trend and the impact of implementing contact screening and SDR-PEP from 2016 to 2040 (25 years) in the Union Territory of Dadra Nagar Haveli (DNH) in India. Effects of the intervention were expressed as disability adjusted life years (DALY) averted under three assumption of disability prevention: 1) all grade 1 disability (G1D) cases prevented; 2) G1D cases prevented in PB cases only; 3) no disability prevented. Costs were US$ 2.9 per contact. Costs and effects were discounted at 3%. The incremental cost per DALY averted by SDR-PEP was US$ 210, US$ 447, and US$ 5,673 in the 25th year under assumption 1, 2, and 3, respectively. If prevention of G1D was assumed, the probability of cost-effectiveness was 1.0 at the threshold of US$ 2,000, which is equivalent to the GDP per capita of India. The probability of cost-effectiveness was 0.6, if no disability prevention was assumed. The cost per new leprosy case averted was US$ 2,873. Contact listing, screening and the provision of SDR-PEP is a cost-effective strategy in leprosy control in both the short (5 years) and long term (25 years). The cost-effectiveness depends on the extent to which disability can be prevented. As the intervention becomes increasingly cost-effective in the long term, we recommend a long-term commitment for its implementation. Author summary: Leprosy is an infectious disease caused by the Mycobacterium leprae and is one of the major causes of preventable disability in low- and middle-income countries. Disabled people face lifelong socioeconomic challenges and are often excluded from society. It brings people affected by leprosy in a vicious cycle of poverty and disability. This cycle needs to be curbed through scientific evidence on health economic aspects of leprosy. Unfortunately, there is not much literature available on cost or cost-effectiveness of leprosy prevention. New prevention methods such as post-exposure chemoprophylaxis are now available, providing opportunity to collect up-to-date health economic evidence to support health policy and planning. Here, we present a cost-effectiveness study of contact screening in combination of post-exposure prophylaxis with single-dose rifampicin in the Union Territory of Dadra Nagar Haveli in India. We compare the intervention with the continuation of the routine leprosy control programme. As leprosy is moving towards elimination, evidence from this study will contribute to an investment case for leprosy elimination. [ABSTRACT FROM AUTHOR]

Leprosy is a chronic infectious disease caused by Mycobacterium leprae (M. leprae) and the more recently discovered Mycobacterium lepromatosis (M. lepromatosis). The two leprosy bacilli cause similar pathologic conditions. They primarily target the skin and the peripheral nervous system. Currently it is considered a Neglected Tropical Disease, being endemic in specific locations within countries of the Americas, Asia, and Africa, while in Europe it is only rarely reported. The reason for a spatial inequality in the prevalence of leprosy in so-called endemic pockets within a country is still largely unexplained. A systematic review was conducted targeting leprosy transmission research data, using PubMed and Scopus as sources. Publications between January 1, 1945 and July 1, 2019 were included. The transmission pathways of M. leprae are not fully understood. Solid evidence exists of an increased risk for individuals living in close contact with leprosy patients, most likely through infectious aerosols, created by coughing and sneezing, but possibly also through direct contact. However, this systematic review underscores that human-to-human transmission is not the only way leprosy can be acquired. The transmission of this disease is probably much more complicated than was thought before. In the Americas, the nine-banded armadillo (Dasypus novemcinctus) has been established as another natural host and reservoir of M. leprae. Anthroponotic and zoonotic transmission have both been proposed as modes of contracting the disease, based on data showing identical M. leprae strains shared between humans and armadillos. More recently, in red squirrels (Sciurus vulgaris) with leprosy-like lesions in the British Isles M. leprae and M. lepromatosis DNA was detected. This finding was unexpected, because leprosy is considered a disease of humans (with the exception of the armadillo), and because it was thought that leprosy (and M. leprae) had disappeared from the United Kingdom. Furthermore, animals can be affected by other leprosy-like diseases, caused by pathogens phylogenetically closely related to M. leprae. These mycobacteria have been proposed to be grouped as a M. leprae-complex. We argue that insights from the transmission and reservoirs of members of the M. leprae-complex might be relevant for leprosy research. A better understanding of possible animal or environmental reservoirs is needed, because transmission from such reservoirs may partly explain the steady global incidence of leprosy despite effective and widespread multidrug therapy. A reduction in transmission cannot be expected to be accomplished by actions or interventions from the human healthcare domain alone, as the mechanisms involved are complex. Therefore, to increase our understanding of the intricate picture of leprosy transmission, we propose a One Health transdisciplinary research approach. Author summary: Leprosy is a chronic infectious disease caused by Mycobacterium leprae (M. leprae) and the more recently discovered Mycobacterium lepromatosis (M. lepromatosis). The two leprosy bacilli cause similar stigmatizing pathologic conditions. M. leprae primarily targets the skin and the peripheral nervous system. Currently it is considered a Neglected Tropical Disease. The transmission pathways of M. leprae are not fully understood. Solid evidence exists of an increased risk for individuals living in close contact with leprosy patients, most likely through infectious aerosols, created by coughing and sneezing, but possibly also through direct contact. However, this systematic review underscores that human-to-human transmission is not the only way leprosy can be acquired. Anthroponotic and zoonotic transmission have both been proposed as modes of contracting the disease, based on data showing identical M. leprae strains shared between humans and armadillos. A better understanding of possible animal or environmental reservoirs is needed, because transmission from such reservoirs may partly explain the steady global incidence of leprosy despite effective and widespread multidrug therapy. Reducing transmission cannot be expected from the human healthcare domain alone, as the mechanisms involved are complex. Therefore, we propose a One Health transdisciplinary research approach. [ABSTRACT FROM AUTHOR]

Understanding the prevalence of M. leprae infection in armadillos is important because of evidence from Brazil and other countries of an association between contact with armadillos and the development of Hansen's Disease (leprosy). Our aim was to characterize studies which have investigated natural M. leprae infection in wild armadillos in Brazil, and to quantify and explore variability in the reported prevalence of infection. We conducted a systematic review (PROSPERO CRD42019155277) of publications in MEDLINE, EMBASE, Global Health, Scopus, LILACS, Biblioteca Digital Brasileira de Teses e Dissertações, Catálogo de Teses e Dissertações de CAPES, and Biblioteca Virtual em Saúde up to 10/2019 using Mesh and text search terms (in English, Portuguese, Spanish, and French). The 10 included studies represented a total sample of 302 armadillos comprising 207 (69%) Dasypus novemcinctus, 67 (22%) Euphractus sexcinctus, 16 (5%) Priodontes maximus, 10 (3%) Cabassous unicinctus, and 2 (1%) Cabassous tatouay from 7 different states. Methods used included histopathology (4 studies), PGL-1 and LID-1 antigen detection (4 studies) and examination for clinical signs of disease (4 studies). Eight studies used PCR of which 7 targeted the RLEP repetitive element and 3 tested for inhibitory substances. M. leprae prevalence by PCR ranged from 0% (in 3 studies) to 100% in one study, with a summary estimate of 9.4% (95% CI 0.4% to 73.1%) and a predictive interval of 0–100%. The average prevalence is equivalent to 1 in 10 armadillos in Brazil being infected with M. leprae, but wide variation in sample estimates means that the prevalence in any similar study would be entirely unpredictable. We propose instead that future studies aim to investigate transmission and persistence of M. leprae within and between armadillo populations, meanwhile adopting the precautionary principle to protect human health and an endangered species in Brazil. Author summary: The risk to human health of contact with armadillos infected with Mycobacterium leprae, a bacterium that causes Hansen's Disease (leprosy), is uncertain, but evidence from Brazil and other countries appears to show a link between contact with armadillos and increased risk of Hansen's Disease in people. How much of Hansen's Disease in the human population is caused by contact with armadillos will depend on the size of the risk, the type and frequency of contact and how common it is in the population, and the role of other (human-to-human) transmission routes for Mycobacterium leprae. Our review has shown that one other key factor, the proportion of wild armadillos infected with Mycobacterium leprae, cannot be predicted with any certainty based on data from studies conducted to date. We suggest that much bigger and longer-term studies are needed, perhaps in partnership with animal conservation and ecology groups, to map Mycobacterium leprae infection in armadillos across Brazil and correlate this with proximity to human habitats. At the same time, data must be gathered in studies focused on populations of armadillos to characterize Mycobacterium leprae transmission and persistence within groups of animals, for example, using trackers and repeated sampling over the animals' lifespans. In the meantime, the precautionary principle should prevail, and public health and educational efforts should be directed to improving community knowledge and changing behaviour to protect people and armadillos. [ABSTRACT FROM AUTHOR]

Background: Several studies have shown that leprosy, podoconiosis and lymphatic filariasis impact individual quality of life. In contrast, family quality of life has not received as much attention despite evidence that families are also affected. This is especially relevant given the crucial role of the family in most societies around the world. This study looks at the impact of leprosy, podoconiosis and lymphatic filariasis on family quality of life. Methodology: The study used a cross-sectional design with a qualitative approach. Both semi-structured interviews and focus group discussions were conducted. Participants, persons affected and their family members, were selected by purposive sampling. Data were collected between August and November 2017 in Awi zone, Northwest Ethiopia and analysed by three independent researchers using open, inductive coding and content analysis. Results: A total of 86 participants were included in this study: 56 participants in the in-depth interviews and 30 participants in the focus group discussions. We found that participation restrictions, reduced productivity and marginalisation were common. In addition, discrimination in the communities occurred often, often extending to family members of persons affected. Divorce and difficulties in finding a spouse were common for persons affected and their family members. Many persons affected reported mental health problems. While most people got social and physical support from their families, there were a few exceptions. In particular, persons with younger children seemed to lack social support. Having to provide for their affected family member sometimes caused stress, school dropouts and an additional workload. Financial problems and loss of livelihood were reported by almost all participants. Conclusion: This study revealed that leprosy, lymphatic filariasis and podoconiosis have an effect on several dimensions of family quality of life. Many problems reported related to stigma and poverty. Author summary: Several studies have shown that leprosy, podoconiosis and lymphatic filariasis impact individual quality of life. In contrast, family quality of life has not received as much attention despite evidence that families are also affected. This is especially relevant given the crucial role of the family in most societies around the world. This study looked at the impact of leprosy, podoconiosis and lymphatic filariasis on family quality of life in Northwest Ethiopia. The study used a cross-sectional design with a qualitative approach. Both semi-structured interviews and focus group discussions were conducted with persons affected and their family members. A total of 86 participants were included in this study: 56 participants in the in-depth interviews and 30 participants in the focus group discussions. This study revealed that leprosy, lymphatic filariasis and podoconiosis have an effect on family quality of life, resulting in: participation restrictions, reduced productivity, marginalisation, discrimination, divorce, difficulties finding a spouse, school dropouts, mental health problems and poverty. Both persons affected and their family members were impacted. Many problems reported related to impairments, stigma and poverty. The results of this study can be used to inform leprosy, lymphatic filariasis and podoconiosis treatment and after care programmes. [ABSTRACT FROM AUTHOR]

Three drugs are unnecessary for treating paucibacillary leprosy - A critique of the WHO guidelines New guidelines have been published by WHO on the diagnosis, treatment, and prevention of leprosy [[1]]. Leprosy reactions, which are associated with nerve damage and disability, occur in more than 60% of patients with MB leprosy during the first 6 months of treatment [[3]]. 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. [Extracted from the article]

Few investigations to date have analyzed the epidemiology of Hansen's disease (leprosy) in the United States, and in particular, if birth location is related to multibacillary versus paucibacillary leprosy. We collected data on 123 patients diagnosed with leprosy in Georgia from the National Hansen's Disease Program from 1923—January 2018. A logistic regression model was built to examine the relationship between country of origin (U.S.-born or immigrant) and the type of leprosy. While the model showed no significant relationship between country of origin and type of leprosy, being Asian or Pacific Islander was associated with a higher odds of multibacillary disease (aOR = 5.71; 95% CI: 1.25–26.29). Furthermore, since the early 1900s, we found an increasing trend of leprosy reports in Georgia among both domestic born and immigrant residents, despite the overall decrease in cases in the United States during the same time period. More research is therefore necessary to further evaluate risk for multibacillary leprosy in certain populations and to create targeted interventions and prevention strategies. Leprosy is often believed to not be an issue in many countries. However, the disease is still very much a problem globally, and in the past several decades has been on the rise in the United States. Frequently the disease is misdiagnosed several times before appropriately treated. Although newly diagnosed cases in the United States only remain around 160 every year, there is limited investigation of leprosy in the United States. As the concern over transmission from armadillos continues to rise, coupled with the increase in connectedness of the global population, it is important to be able to identify populations at higher risk for the more infectious form of leprosy, multibacillary leprosy, for targeted interventions. The researchers sought to investigate which populations are at higher risk for this more infectious form, while also describing the history of cases in the state of Georgia. By adding to the body of literature on leprosy in the United States, it is the hope that more research will be produced that provides a better understanding of the disease trends within the country, while also enabling more targeted interventions. [ABSTRACT FROM AUTHOR]

Background: Although leprosy is largely curable with multidrug therapy, incomplete treatment limits therapeutic effectiveness and is an important obstacle to disease control. To inform efforts to improve treatment completion rates, we aimed to identify the geographic and socioeconomic factors associated with leprosy treatment default in Brazil. Methodology/Principal findings: Using individual participant data collected in the Brazilian national registries for social programs and notifiable diseases and linked as part of the 100 Million Brazilian Cohort, we evaluated the odds of treatment default among 20,063 leprosy cases diagnosed and followed up between 2007 and 2014. We investigated geographic and socioeconomic risk factors using a multivariate hierarchical analysis and carried out additional stratified analyses by leprosy subtype and geographic region. Over the duration of follow-up, 1,011 (5.0%) leprosy cases were observed to default from treatment. Treatment default was markedly increased among leprosy cases residing in the North (OR = 1.57; 95%CI 1.25–1.97) and Northeast (OR = 1.44; 95%CI 1.17–1.78) regions of Brazil. The odds of default were also higher among cases with black ethnicity (OR = 1.29; 95%CI 1.01–1.69), no income (OR = 1.41; 95%CI 1.07–1.86), familial income ≤ 0.25 times Brazilian minimum wage (OR = 1.42; 95%CI 1.13–1.77), informal home lighting/no electricity supply (OR = 1.53; 95%CI 1.28–1.82), and household density of > 1 individual per room (OR = 1.35; 95%CI 1.10–1.66). Conclusions: The findings of the study indicate that the frequency of leprosy treatment default varies regionally in Brazil and provide new evidence that adverse socioeconomic conditions may represent important barriers to leprosy treatment completion. These findings suggest that interventions to address socioeconomic deprivation, along with continued efforts to improve access to care, have the potential to improve leprosy treatment outcomes and disease control. [ABSTRACT FROM AUTHOR]

Objective: The diagnosis of paucibacillary (PB) leprosy cases remains a challenge because of the absence of a confirmatory laboratory method. While quantitative polymerase chain reaction (qPCR) has been shown to provide reliable sensitivity and specificity in PB diagnoses, a thorough investigation of its efficacy in clinical practice has not yet been published. The present study evaluated patients with suspected leprosy skin lesions by using qPCR to identify PB individuals in the Leprosy Outpatient clinic at the Oswaldo Cruz Foundation in Rio de Janeiro, Brazil. Methods: One hundred seventy-two suspected PB cases were included in the study. The patients were evaluated by a dermatologist at three different times. The clinical dermato-neurological examination and collected samples were performed on the first visit. On the second visit, the results of the histopathological analysis and PCR assay (DNA-based Mycobacterium leprae qPCR-targeting 16S gene) results were analyzed, and a decision regarding multi-drug therapy was made. A year later, the patients were re-examined, and the consensus diagnosis was established. Results: In 58% (100/172) of cases, a conclusive diagnosis via histopathological analysis was not possible; however, 30% (30/100) of these cases had a positive PCR. One hundred ten patients (110/172) attended the third visit. The analysis showed that while the sensitivity of the histopathological test was very low (35%), a qPCR alone was more effective for identifying leprosy, with 57% sensitivity. Conclusion: The use of qPCR in suspected PB cases with an inconclusive histology improved the sensitivity of leprosy diagnoses. [ABSTRACT FROM AUTHOR]

Background: Neglected tropical diseases (NTDs) are communicable diseases that impact approximately 1 billion people, but receive relatively little research, funding, and attention. Many NTDs have similar treatments, epidemiology, and geographic distribution, and as a result, the integration of control efforts can improve accountability, efficiency, and cost-effectiveness of programs. Here, we examine the landscape of efforts towards NTD integration across countries with the highest burden of disease, and review the administrative management of integration in order to identify approaches and pathways for integration. Methodology and principal findings: We utilized a standardized system to score countries for NTD endemnicity to create a list of 25 countries with the highest overall burden of NTDs. We then conducted a literature review to characterize the NTD control programs in the focus countries. Six countries were selected for key informant interviews to validate literature review results and gather additional data on opportunities and obstacles to NTD integration, from an administrative perspective. The majority of countries included in the study were located in Africa, with the remainder from Asia, North America, and South America. Multiple models and pathways were observed for the integration of NTD programs, in combination with other NTD programs, other diseases, or other health programs. Substantial heterogeneity existed with respect to the NTD control programs, and no country had integrated all of their NTD control efforts into a single program. NTDs that can be treated with preventative chemotherapy were frequently integrated into a single program. Leprosy control was also frequently integrated with those of other communicable diseases, and notably tuberculosis. Barriers to NTD integration may result from internal administrative obstacles or external obstacles. Conclusions: Although many countries have begun to integrate NTD control efforts, additional work will be required to realize the full benefits of integration in most of the countries examined here. Moving forward, NTD integration efforts must ensure that administrative structures are designed to maximize the potential success of integrated programs and account for existing administrative processes. [ABSTRACT FROM AUTHOR]