Abstract
BackgroundMajor depressive disorder (MDD) associated with chronic neglected tropical diseases (NTDs) has been identified as a significant and overlooked contributor to overall disease burden. Cutaneous leishmaniasis (CL) is one of the most prevalent and stigmatising NTDs, with an incidence of around 1 million new cases of active CL infection annually. However, the characteristic residual scarring (inactive CL) following almost all cases of active CL has only recently been recognised as part of the CL disease spectrum due to its lasting psychosocial impact.Methods and findingsWe performed a multi-language systematic review of the psychosocial impact of active and inactive CL. We estimated inactive CL (iCL) prevalence for the first time using reported WHO active CL (aCL) incidence data that were adjusted for life expectancy and underreporting. We then quantified the disability (YLD) burden of co-morbid MDD in CL using MDD disability weights at three severity levels. Overall, we identified 29 studies of CL psychological impact from 5 WHO regions, representing 11 of the 50 highest burden countries for CL. We conservatively calculated the disability burden of co-morbid MDD in CL to be 1.9 million YLDs, which equalled the overall (DALY) disease burden (assuming no excess mortality in depressed CL patients). Thus, upon inclusion of co-morbid MDD alone in both active and inactive CL, the DALY burden was seven times higher than the latest 2016 Global Burden of Disease study estimates, which notably omitted both psychological impact and inactive CL.ConclusionsFailure to include co-morbid MDD and the lasting sequelae of chronic NTDs, as exemplified by CL, leads to large underestimates of overall disease burden.
Highlights
Cutaneous leishmaniasisCutaneous leishmaniasis (CL) is the most prevalent form of leishmaniasis and 1 of 22 highly prevalent neglected tropical diseases (NTD) [1]
We show the contribution of inactive CL to the overall disease burden estimates when included, which is due to the large psychological impact it has on those affected by it
Such a classification is inclusive of long-term sequelae such as mucocutaneous leishmaniasis (MCL), which develops in a minority of CL cases (~4%) [4] mainly in the Americas and East African regions and which may represent a reactive form of CL [5]
Summary
Cutaneous leishmaniasisCutaneous leishmaniasis (CL) is the most prevalent form of leishmaniasis and 1 of 22 highly prevalent neglected tropical diseases (NTD) [1]. We recently expanded the spectrum of CL disease by introducing new terminology—active (aCL) and inactive (iCL) scarring cutaneous leishmaniasis—to describe the dermatological changes of CL in relation to its disease activity [3] Such a classification is inclusive of long-term sequelae such as mucocutaneous leishmaniasis (MCL), which develops in a minority of CL cases (~4%) [4] mainly in the Americas and East African regions and which may represent a reactive form of CL [5]. The stigmatisation resulting from visible active and inactive CL lesions can be traced back centuries and was probably a major driver in establishing the ancient practice of leishmanisation [6] This defining psychosocial aspect of cutaneous leishmaniasis has been almost completely overlooked by successive disease burden studies [7,8,9,10]. The characteristic residual scarring (inactive CL) following almost all cases of active CL has only recently been recognised as part of the CL disease spectrum due to its lasting psychosocial impact
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