Comprehensive measures succeeded in improving early detection of leprosy cases in post-elimination era: Experience from Shandong province, China

High-risk spatiotemporal patterns of leprosy in the southeastern region of Yunnan province from 2010 to 2022: an analysis at the township level

BACKGROUND

Despite being preventable and curable, leprosy remains endemic in some undeveloped regions, including China. Wenshan Zhuang and Miao Autonomous Prefecture (Wenshan prefecture) currently bears the highest leprosy burden in China. In this ecological study, we aimed to analyze the epidemiological characteristics as well as identify and visualize the high-risk townships of Wenshan prefecture using the most updated leprosy data from 2010 to 2022.

METHODS

Geographical information system combined with spatial scan statistics was used for newly detected leprosy cases abstracted from the Leprosy Management Information System in China. Global Moran's I index was used to uncover the spatial pattern of leprosy at the township level. Spatial scan statistics, encompassing purely temporal, purely spatial, spatial variation in temporal trends, and space-time analysis, were implemented for detecting the risk clusters.

RESULTS

Between 2010 and 2022, Wenshan prefecture detected 532 new leprosy cases, comprising 352 (66.17%) males and 180 (33.83%) females. The aggregated time primarily occurred between October 2010 and March 2014. The distribution pattern of newly detected leprosy cases was spatially clustered. We identified four high-risk spatial clusters encompassing 54.51% of the new cases. Furthermore, spatial variation in temporal trends highlighted one cluster as a potential high-risk area. Finally, two space-time clusters were detected, and the most likely cluster was predominantly located in the central and northwest regions of Wenshan prefecture, spanning from January 2010 to September 2013.

CONCLUSIONS

In this ecology study, we characterized the epidemiological features and temporal and spatial patterns of leprosy in Wenshan prefecture using the most recent leprosy data between 2010 and 2022. Our findings offer scientific insights into the epidemiological profiles and spatiotemporal dynamics of leprosy in Wenshan prefecture. Clinicians and policymakers should pay particular attention to the identified clusters for the prevention and control of leprosy.

The burden of skin diseases in China: global burden of Disease Study 2019

Skin diseases continue to affect human health and cause a significant disease burden on the healthcare system.We aimed to report the changing trends in the burden of skin disease in China from 1990 to 2019, Which has an important role in developing targeted prevention strategies. We applied Global Burden of Disease, Injuries, and Risk Factors Study (GBD) 2019 analytical tools to calculate the age-standardized Prevalence and Incidence in 2019, number of years lived with disability (YLDs) and age-standardized YLDs from 1990 to 2019 of skin and subcutaneous diseases, notifiable infectious skin diseases and skin tumors in China. Among the skin and subcutaneous diseases in China in 2019, dermatitis contributed to the greatest YLD (2.17 million, 95% uncertainty interval[UI]: 1.28-3.36). Age-standardized YLD rates for leprosy decreased from 0.09 (95%UI: 0.06-0.13) in 1990 to 0.04 (95%UI: 0.03-0.06) in 2019; the proportional decrease was 55.56% over 30 years. Age-standardized YLDs for HIV and sexually transmitted infections increased by 26% during the same time period. Age-standardized YLDs for non-melanoma skin cancer increased at a much higher rate than melanoma between 1990 and 2019. Dermatitis and scabies continue to have an important role in the burden of skin and subcutaneous disease burden in China. The burden of non-melanoma cell cancer has increased most significantly over the past three decades.

Individual, socioeconomic and healthcare access factors influencing the delays in leprosy presentation, diagnosis and treatment: a qualitative study

BACKGROUND

This study investigated the factors influencing the presentation, diagnosis and treatment of leprosy in primary healthcare.

METHODS

Qualitative research was conducted on patients undergoing treatment in a priority hyperendemic region for leprosy control in northeastern Brazil. Interviews were conducted between September and December 2020 at primary healthcare centers. Data were analysed based on the basic interpretive qualitative structure according to Andersen and Newman's model of healthcare utilisation.

RESULTS

Knowledge of leprosy symptoms influenced patients' search for a diagnosis. Unfavorable socioeconomic conditions experienced by patients made diagnosis and treatment difficult. Incorrect evaluations by health professionals caused difficulties and delays in obtaining a diagnosis of leprosy. Perceptions about the disease, such as non-acceptance of the disease and the adverse effects of the medications, affected treatment seeking and treatment continuity.

CONCLUSIONS

Patients with leprosy faced delays and healthcare access barriers related to knowledge of the disease, socioeconomic conditions and the structure of healthcare services, which must be considered when creating care plans, surveillance and control actions against leprosy. Appropriate interventions are necessary to reduce delays and better control the disease.

Prevalence and risk factors for disability in leprosy patients in Indonesia during the post-elimination era

Leprosy has been nationally eliminated in Indonesia, but it continues to be a public health problem, with disability contributing to the disease burden. Disability caused by leprosy often results in stigmatization, leading to decreased quality of life. This was a retrospective cross-sectional study using secondary data from primary healthcare centers in one of the districts in the region with the highest number of leprosy patients in Indonesia. All leprosy patients between 2016-2022 were included. Among 189 leprosy patients (mean age 46 years old, 65.6% male), 19% had grade 1 disability and 29.6% had grade 2 disability. Duration of disease, nerve enlargements, leprosy reactions, and symmetric lesions were identified as risk factors for both grade 1 and 2 disability. Being male and having a positive smear test was associated with a higher risk of only grade 2 disability. Disability due to leprosy is still prevalent in the post-elimination era despite the decline in new leprosy cases. Improvement in early case detection and prevention of disability are still needed in the post-elimination era.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Establishing a standard method for analysing case detection delay in leprosy using a Bayesian modelling approach

BACKGROUND

Leprosy is an infectious disease caused by Mycobacterium leprae and remains a source of preventable disability if left undetected. Case detection delay is an important epidemiological indicator for progress in interrupting transmission and preventing disability in a community. However, no standard method exists to effectively analyse and interpret this type of data. In this study, we aim to evaluate the characteristics of leprosy case detection delay data and select an appropriate model for the variability of detection delays based on the best fitting distribution type.

METHODS

Two sets of leprosy case detection delay data were evaluated: a cohort of 181 patients from the post exposure prophylaxis for leprosy (PEP4LEP) study in high endemic districts of Ethiopia, Mozambique, and Tanzania; and self-reported delays from 87 individuals in 8 low endemic countries collected as part of a systematic literature review. Bayesian models were fit to each dataset to assess which probability distribution (log-normal, gamma or Weibull) best describes variation in observed case detection delays using leave-one-out cross-validation, and to estimate the effects of individual factors.

RESULTS

For both datasets, detection delays were best described with a log-normal distribution combined with covariates age, sex and leprosy subtype [expected log predictive density (ELPD) for the joint model: -1123.9]. Patients with multibacillary (MB) leprosy experienced longer delays compared to paucibacillary (PB) leprosy, with a relative difference of 1.57 [95% Bayesian credible interval (BCI): 1.14-2.15]. Those in the PEP4LEP cohort had 1.51 (95% BCI: 1.08-2.13) times longer case detection delay compared to the self-reported patient delays in the systematic review.

CONCLUSIONS

The log-normal model presented here could be used to compare leprosy case detection delay datasets, including PEP4LEP where the primary outcome measure is reduction in case detection delay. We recommend the application of this modelling approach to test different probability distributions and covariate effects in studies with similar outcomes in the field of leprosy and other skin-NTDs.

Epidemiological characteristics of leprosy during the period 2005-2020: A retrospective study based on the Chinese surveillance system

Background

Jiangsu Province is located in the Yangtze River Delta region, with a total area of 107,200 square kilometers. Since 1949, over 55,000 cases have been registered, with Taixing accounting for the highest number of patients. The proportion of new cases with MB and G2D was higher compared to other regions. As a result, Jiangsu has been considered a priority area for public health interventions in China.

Methods

This paper mainly described the population, time, and spatial distribution of the newly detected leprosy cases in Jiangsu Province between 2005 and 2020. In this study, all the data were entered into Microsoft Excel and SPSS for the descriptive analysis. ArcGIS was applied to create statistical maps, and Geoda was used to conduct spatial autocorrelation analysis with local Moran's I statistics (LISA). The epidemiological data were obtained from LEPMIS. In addition, population data were obtained from the Statistical Yearbook of Jiangsu Province.

Results

During the study period, 363 new cases were reported. Of these, 232 were men and 131 were women (1.77:1). The mean age at diagnosis was 60.56 years, and no adolescent cases were identified. Three hundred and twenty-seven (90.08%) were diagnosed with MB and 36 (9.92%) with PB. 31.68% (115/363) of the patients presented with G2D. Farmers accounted for 74.9%, and most cases were identified in skin clinics (248, 68.32%). We observed a decreasing trend in detection rate, with a higher concentration of new cases diagnosed between July and October. Spatial analysis showed that the new cases were primarily distributed in the northwest of Jiangsu province, and Suqian has the highest incidence of leprosy. Special attention should be paid to Wuzhong, a county with a potential risk of inter-provincial transmission. Furthermore, 55 new cases came from other Chinese provinces but lived in Jiangsu.

Conclusion

The NCDR of leprosy decreased, but the new cases showed disabilities, a sign of the late diagnosis. The results indicated that some regions were still suffering from the burden of leprosy. Thus, we recommend that the government should adopt effective strategies to promote leprosy control. The main priorities for eliminating new cases were to provide sustainable financial support, improve the quality of clinical services, strengthen preventive intervention and rehabilitation services for disabilities, provide health education among high-risk populations, and explore new approaches.

Determinants of patients' delay with disability in the diagnosed leprosy cases in the three major states of India: A case-control study

BACKGROUND

Skin lesions are the most common early symptoms of leprosy, often ignored by patients at an early stage and misdiagnosed as other dermatological diseases by healthcare personnel, leading to delay in diagnosis and treatment of leprosy precipitating permanent neurological deficit, deformities and serious disabilities.

AIMS

The objective is to evaluate the duration of delay and factors responsible for the delay in reporting of patients, among the newly detected leprosy cases (Grade 1 and Grade 2 disability patients).

METHODS

A case-control study was conducted during 2014-2016 in three major states of India (Delhi, Gujarat and West Bengal) in 140 randomly recruited newly registered adult leprosy patients (aged 18 years and above) with Grade 2/1 disabilities (cases) and 140 Grade 0 disability patients (controls) in each of these Indian states.

RESULTS

It is established that the major contributors for the delay in the early diagnosis of leprosy have been patient-related factors. The median patient delay in the three states of Delhi, Gujarat and West Bengal were five months (0.7-1.8), 2.8 months (2-14) and 12 months (2-24), respectively.

LIMITATIONS

The study design is case-control and has an inbuilt reporting bias due to the retrospective nature of data collection but the data collection was carried with caution to reduce the recall bias. As the study is carried out in three states, generalisation of interpretation was cautiously executed. The matching ratio of cases and controls was 1:1 in this study, but we could not increase the controls due to operational feasibility during the conduct of the study.

CONCLUSION

Patient delay is a crucial factor responsible for the disability among new leprosy cases. A higher patient delay in these three states reflects that the community is not aware about the signs and symptoms of leprosy. Reducing patient delay is very important for reducing disabilities in the newly diagnosed cases.

Delayed detection of leprosy cases: A systematic review of healthcare-related factors

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, 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.

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.

Suspicious symptom monitoring for leprosy: an optimal practice for early detection under a low endemic situation in Zhejiang Province, China

BACKGROUND

Leprosy is a chronic infectious disease that causes disabilities and deformities. Early detection is a major strategy for leprosy control. This study reported a new practice of suspicious symptom monitoring for early detection of leprosy.

METHODS

A descriptive and comparative analysis between a non-strategy group of pre-implementation of suspicious symptom monitoring in 2005-2011 and a strategy group of strategy implementation in 2012-2018 was conducted through indicators of the number of times of misdiagnoses, delayed period, proportion of early detected cases, and proportion of disabilities.

RESULT

Compared with the non-strategy group in 2005-2011, the median number of times of misdiagnoses was decreased from two times to zero times (z = 4.387, P < 0.001), and the median delayed period of newly detected cases were shortened from 24 months to 13 months (z = 2.381, P < 0.001), the proportion of early detected cases was increased from 43.7% to 75.2% (χ²  = 29.464, P < 0.001), the proportion of grade 2 disabilities was decreased from 28.6% in the highest year of 2005 to 4.0% in the lowest year of 2014, and the average proportion of disabilities was decreased from 33.5% to 17.6% (χ²  = 9.421, P = 0.002) in the strategy group in 2012-2018, respectively.

CONCLUSION

Suspicious symptom monitoring promoted early detection of cases by reducing the number of times misdiagnosis of leprosy patients, shortening the delayed period, increasing the proportion of early detection, and decreasing the proportion of disabilities. It is an important and recommendable public health strategy for leprosy prevention and control in a low epidemic condition.

Hansenapp: development of a mobile application to assist primary healthcare providers to control leprosy

OBJECTIVE

To describe the development and validation of a mobile application to assist health professionals in the management of patients with leprosy and surveillance of contacts in primary healthcare.

METHOD

A methodological and developmental study was conducted in three phases: integrative literature review, mobile application development, and application validation by health professionals. The construction of the application was supported by the literature review, Nielsen's heuristics, and expert validation. Five experts individually analyzed the prototype draft and performed two rounds of iterations to refine their recommendations. The validation step was performed by consulting health professionals working in primary healthcare, who evaluated the application for relevance, clarity and usability using a questionnaire based on task-technology fit theory.

RESULTS

The mobile app's content, navigation methods, and interaction were refined based on the discussions with experts. Their recommendations were applied, and the mobile app was revised until the final version was approved. Content validity indexes of 0.94 (p = 0.007), 0.99 (p > 0.0001), and 0.93 (p = 0.01) were obtained.

CONCLUSION

The developed application is a technological tool that could assist primary healthcare providers in dealing with leprosy patients and their contacts in terms of management, planning, monitoring, evaluation, treatment, and follow-up, in addition to leprosy control actions. This article is protected by copyright. All rights reserved.

Individual and community factors determining delayed leprosy case detection: A systematic review

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.

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.

Scoping review of Neglected Tropical Disease Interventions and Health Promotion: A framework for successful NTD interventions as evidenced by the literature

Background

Neglected Tropical Diseases (NTDs) affect more than one billion people globally. A Public Library of Science (PLOS) journal dedicated to NTDs lists almost forty NTDs, while the WHO prioritises twenty NTDs. A person can be affected by more than one disease at the same time from a range of infectious and non-infectious agents. Many of these diseases are preventable, and could be eliminated with various public health, health promotion and medical interventions. This scoping review aims to determine the extent of the body of literature on NTD interventions and health promotion activities, and to provide an overview of their focus while providing recommendations for best practice going forward. This scoping review includes both the identification of relevant articles through the snowball method and an electronic database using key search terms. A two-phased screening process was used to assess the relevance of studies identified in the search–an initial screening review followed by data characterization using the Critical Appraisal Skills Program (CASP). Studies were eligible for inclusion if they broadly described the characteristics, methods, and approaches of (1) NTD interventions and/or (2) community health promotion.

Principal findings

90 articles met the CASP criteria partially or fully and then underwent a qualitative synthesis to be included in the review. 75 articles specifically focus on NTD interventions and approaches to their control, treatment, and elimination, while 15 focus specifically on health promotion and provide a grounding in health promotion theories and perspectives. 29 of the articles provided a global perspective to control, treatment, or elimination of NTDs through policy briefs or literature reviews. 19 of the articles focused on providing strategies for NTDs more generally while 12 addressed multiple NTDs or their interaction with other infectious diseases. Of the 20 NTDs categorized by the WHO and the expanded NTD list identified by PLOS NTDs, several NTDs did not appear in the database search on NTD interventions and health promotion, including yaws, fascioliasis, and chromoblastomycosis.

Conclusions

Based on the literature we have identified the four core components of best practices including programmatic interventions, multi sectoral and multi-level interventions, adopting a social and ecological model and clearly defining ‘community.’ NTD interventions tend to centre on mass drug administration (MDA), particularly because NTDs were branded as such based on their being amenable to MDA. However, there remains a need for intervention approaches that also include multiple strategies that inform a larger multi-disease and multi-sectoral programme. Many NTD strategies include a focus on WASH and should also incorporate the social and ecological determinants of NTDs, suggesting a preventative and systems approach to health, not just a treatment-based approach. Developing strong communities and incorporating social rehabilitation at the sublocation level (e.g. hospital) could benefit several NTDs and infectious diseases through a multi-disease, multi-sectoral, and multi-lateral approach. Finally, it is important the ‘community’ is clearly defined in each intervention, and that community members are included in intervention activities and viewed as assets to interventions.

Neglected Tropical Diseases (NTDs) affect more than one billion people globally. A person can be affected by more than one disease at the same time. Many of these diseases are preventable, and could be eliminated with various public health, health promotion and medical interventions. This scoping review aims to determine the extent of the body of literature on NTD interventions and health promotion activities, and to provide an overview of their focus while providing recommendations for best practice going forward. Through a database search and by identifying appropriate literature 75 articles were identified that specifically focus on NTD interventions and approaches to their control, treatment, and elimination, while 15 focus specifically on health promotion and provide a grounding in health promotion theories and perspectives. Based on the literature we have identified the four core components of best practices including programmatic interventions, multi sectoral and multi-level interventions, adopting a social and ecological model and clearly defining ‘community.’

Factors Influencing Leprosy Incidence: A Comprehensive Analysis of Observations in Wenshan of China, Nepal, and Other Global Epidemic Areas

Leprosy remains endemic in some regions and is a global health concern. However, the possible causes and risk factors of the disease remain unclear. Data in Wenshan, China were collected from the Wenshan Institute of Dermatology (1986-2015); data in Nepal were obtained from the Leprosy Control Division, Department of Health Services, Nepal (2011 to 2015); and data from Indonesia, India, and Brazil were collected from WHO records. We assessed the epidemiological trends of leprosy in Wenshan and compared the features of possible causes and risk factors with those of other countries. We then performed a descriptive and statistical analysis to make our study more purposeful and definitive. A total of 3,376 cases were detected in Wenshan from 1986 to 2015. The overall prevalence rate (PR) of leprosy presented a decreasing trend with a peak (4.9/10,000 population) in 1986. The detection of new leprosy cases was higher in males than in females. Visible deformity increased every year since 2005 with a disability of 34.8% in 2015 among new cases. In Nepal, 2,461 leprosy patients received multi-drug therapy (MDT) in 2015 which corresponded to the PR of 0.89/10,000 population. Geographic latitude and socio-economic situations appeared to be the main causes of leprosy, and the healthcare condition was an important factor associated with leprosy incidence. The introduction of MDT effectively reduced leprosy prevalence worldwide. Wenshan (China), Nepal, and other countries share similarities in various aspects with respect to socio-cultural features, geographical distribution, environmental factors, and economic situation, which may contribute to leprosy being endemic in these areas.

Mycobacterium leprae transmission characteristics during the declining stages of leprosy incidence: A systematic review

BACKGROUND

Leprosy is an infectious disease caused by Mycobacterium leprae. As incidence begins to decline, the characteristics of new cases shifts away from those observed in highly endemic areas, revealing potentially important insights into possible ongoing sources of transmission. We aimed to investigate whether transmission is driven mainly by undiagnosed and untreated new leprosy cases in the community, or by incompletely treated or relapsing cases.

METHODOLOGY/PRINCIPAL FINDINGS

A literature search of major electronic databases was conducted in January, 2020 with 134 articles retained out of a total 4318 records identified (PROSPERO ID: CRD42020178923). We presented quantitative data from leprosy case records with supporting evidence describing the decline in incidence across several contexts. BCG vaccination, active case finding, adherence to multidrug therapy and continued surveillance following treatment were the main strategies shared by countries who achieved a substantial reduction in incidence. From 3950 leprosy case records collected across 22 low endemic countries, 48.3% were suspected to be imported, originating from transmission outside of the country. Most cases were multibacillary (64.4%) and regularly confirmed through skin biopsy, with 122 cases of suspected relapse from previous leprosy treatment. Family history was reported in 18.7% of cases, while other suspected sources included travel to high endemic areas and direct contact with armadillos. None of the countries included in the analysis reported a distinct increase in leprosy incidence in recent years.

CONCLUSIONS/SIGNIFICANCE

Together with socioeconomic improvement over time, several successful leprosy control programmes have been implemented in recent decades that led to a substantial decline in incidence. Most cases described in these contexts were multibacillary and numerous cases of suspected relapse were reported. Despite these observations, there was no indication that these cases led to a rise in new secondary cases, suggesting that they do not represent a large ongoing source of human-to-human transmission.

Towards the elimination of leprosy in Yunnan, China: A time-series analysis of surveillance data

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.

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.

Novel Diagnostics for Kaposi Sarcoma and Other Skin Diseases in Resource-Limited Settings

In resource-limited settings, point-of-care diagnostic devices have the potential to reduce diagnostic delays and improve epidemiologic surveillance of dermatologic conditions. We outline novel-point-of care diagnostics that have recently been developed for dermatologic conditions that primarily affect patients living in resource-limited settings, namely, Kaposi sarcoma, cutaneous leishmaniasis, leprosy, Buruli ulcer, yaws, onchocerciasis, and lymphatic filariasis. All of the technologies described in this article are prototypes, and some have undergone field testing. These devices still require validation in real-world settings and effective pricing to have a major impact on dermatologic care in resource-limited settings.