Leprosy Control Activities Research Articles

Leprosy epidemiology in Daoukro health district (Côte d'Ivoire) from 1999 to 2017

Leprosy is a real problem in the Daoukro health district despite the actions of the National programme for elimination. To describe the epidemiological and clinical profile of new leprosy cases in the Daoukro health district from 1999 to 2017. Descriptive survey including leprosy patients admitted to the dermato-leprology department from 1999 to 2017. From 1999 to 2017, the incidence of leprosy fluctuated from 4.4 to 0 per 100,000 with a peak of 14.2 in 2003. In 2016 and 2017 no cases of leprosy were reported. The mean age was 36.8 years (SD=20). A majority of cases were uneducated and living in rural areas. Females and children under 15 years of age accounted for 53% and 16% of cases respectively. Clinically, cutaneous signs were predominant in the patients. The multibacillary form accounted for 82%. Nearly 1 out of 4 patients had a grade 2 disability (24%). All patients received treatment (multidrug therapy). Among them, 83.8% were cured, while 0.5% were not cured. In addition, regarding 29 patients (15.7%) details of how their disease progressed were not available. Among the patients declared cured, 26% had sequels. Leprosy control activities must be strengthened in order to maintain the achievements in this non-endemic district.

Spatial analysis reveals failures in leprosy control activities in a hyperendemic city in Brazil

Spatial analysis reveals failures in leprosy control activities in a hyperendemic city in Brazil

Improved leprosy elimination efforts in Somalia, 2015–2021: achievements in a challenging environment and the way forward

Background Since leprosy was eliminated as a public health problem in 2000, trends in case detection have been declining. However, from 2015, case detection in the WHO Eastern Mediterranean (EM) region increased mainly due to reports from Somalia that re-instated the national programme. As Somalia reported 57% of new cases in the EM region in 2021, we reviewed the national control programme activities and the characteristics of reported cases to understand leprosy transmission in the country. Methods From 2012 to 2021, we extracted data from WHO’s Global Health Observatory and the national leprosy control programme’s patient register in Somalia. From 2015 onwards, leprosy cases were detected by the Federal Ministry of Health through mobile teams conducting “skin camps” in 47 districts across seven regions. We analyzed data to describe the overall case detection rate and rates per period, place and person, including severity measured by grade two disability (G2D) and multibacillary (MB) cases. Results The overall case detection rate increased 11-fold between 2012 and 2021, from 6 cases per million in 2012 to 106 cases per million in 2021 in females and from 16 cases per million in 2012 to 132 cases per million in 2021 in males. Case detection among children under 15-years of age also increased from 4 cases per million in 2012 to 13 cases per million in 2021. Initially, the proportion of MB cases and G2D at the time of diagnosis increased from 60% and 11% in 2012 to 87% and 42% in 2015 respectively, when the national programme resumed leprosy control activities. By 2021, the MB proportion decreased to 45% and G2D proportion also decreased to 2%. From 2015 to 2021, four regions in Somalia reported 77% of the new cases and 83% of cases with G2D: Lower Shabelle, Middle Juba, Lower Juba and Middle Shabelle. Conclusion “Skin-camps” for case detection were effective in finding hidden leprosy cases and reducing the delay in diagnosis over time. The constant case detection rate among the female population, equal to the male population, points to sufficient programme reach. However, low disability rates persisted among this population which could be due to continued underlying stigma. Reports of new cases among children suggest ongoing transmission requiring prevention strategies such as single dose rifampicin post-exposure prophylaxis.

Effectiveness of population-wide screening and mass drug administration for leprosy control in Kiribati: the COMBINE protocol

IntroductionProgress towards leprosy elimination is threatened by increasing incidence in ‘hot-spot’ areas where more effective control strategies are urgently required. In these areas, active case finding and leprosy prevention limited...

Clinico-Epidemiological profile of new leprosy cases detected in leprosy case detection campaign in North Maharashtra during 2018-2020.

Leprosy is a leading cause of disability in India. The percentage of disability and deformity can be reduced by diagnosing leprosy at an early stage. In order to detect the hidden leprosy cases, leprosy case detection campaigns, on line with Pulse Polio Campaign have been introduced specifically for high endemic districts, by the Central Leprosy Division. Records of cases from 2018 to 2020 were evaluated retrospectively to study the trend of new cases. The present study denotes the presence of hidden undiagnosed cases in the community and will require an intensification of leprosy control activities through contact tracing and active case detection. Continued quality surveillance is required for early detection, timely management, and prevention of the spread of the disease.

Prolonged delays in leprosy case detection in a leprosy hot spot setting in Eastern Ethiopia.

BackgroundLeprosy or Hansen’s disease is known to cause disability and disfigurement. A delay in case detection of leprosy patients can lead to severe outcomes. In Ethiopia, the disability rates caused by leprosy among new cases are relatively high compared to other endemic countries. This suggests the existence of hidden leprosy cases in the community and a delay in timely detection. To reduce disability rates, it is crucial to identify the factors associated with this delay. This study aimed to determine the extent of delay in case detection among leprosy cases in Eastern Ethiopia.MethodsThis cross-sectional explorative study was conducted in January and February 2019 among 100 leprosy patients diagnosed ≤6 months prior to inclusion. A structured questionnaire was used to collect data, including the initial onset of symptoms, and the reasons for delayed diagnosis. Descriptive statistics, including percentages and medians, were used to describe the case detection delay. Logistic regression analysis was carried out to evaluate the predictors of delay in case detection of >12 months.FindingsThe median age of patients was 35 years, with a range of 7 to 72 years. The majority were male (80%) and rural residents (90%). The median delay in case detection was 12 months (interquartile range 10–36 months) among the included patients. The mean delay in case detection was 22 months, with a maximum delay of 96 months. The overall prevalence of disability among the study population was 42% (12% grade I and 30% grade II). Fear of stigma (p = 0.018) and experiencing painless symptoms (p = 0.018) were highly associated with a delay in case detection of >12 months.ConclusionsBeing afraid of stigma and having painless symptoms, which are often misinterpreted as non-alarming at the onset of the disease, were associated with a delay in case detection. This study showed the need to increase knowledge on early symptoms of leprosy among affected communities. Furthermore, it is important to support initiatives that reduce leprosy related stigma and promote health worker training in leprosy control activities.

LEPROSY A CHANGE IN PROFILE?

Leprosy has been ofcially eliminated from India since December, 2005; still there are districts and blocks reporting high prevalence indicating ongoing transmission. Thepresent study aimed at determining the current situation/scenario of leprosy in a tertiary level hospital in Kolkata.It is a cross-sectional observational study carried out on patients diagnosed and registered in the leprosy clinic (May 2018-May 2020).Data regarding clinical features, histopathological diagnosis and treatment, reactions was analyzed. Skin biopsies were taken in all cases and slit skin smear was done. The biopsies and slit skin smear were evaluated for the type of pathology and acid fast bacilli (AFB) status. A total of 58 patients were registered over 8months period, with M: F (4.8:1). 5child cases were reported, 44 (75.86%) were new cases, 14 (24.14%) were defaulter. Slit skin smear showed 37 (63.79%) cases were multibacillary (MB). Lepromatous leprosy (LL) 28 (48.28%) was the most frequent morphologic type followed by borderline tuberculoid (BT) 12 (20.69%) andtuberculoid leprosy 9 (15.52%) borderline lepromatous(BL) 4 (6.89%) cases, 5 (8.62%) case of histoid leprosy. 9 (15.51%) presented with each type 1 and 5 (8.62%) cases with type 2Erythema NodosumLeprosum (ENL) reaction.Our studyoffers insight into the current status of the disease in the area of otherwise low prevalence. It is seen that despite statistical elimination, lepromatus leprosy, leprosy reactions are commonly seen as presenting features. It highlights the need for continuation of targeted leprosy control activities and active case detection.

Leprosy Update in China, 2019

Abstract Objective: To study the epidemiology of leprosy in China in 2019 and give suggestions to improve future leprosy control activities. Methods: We collected leprosy data from the Leprosy Management Information System in China, which includes data from 31 Chinese provinces, autonomous regions, and municipalities, except for Hong Kong, Macao, and Taiwan. We then performed a descriptive analysis of these data. Results: A total of 464 new leprosy cases were reported nationwide in 2019, with a case detection rate of 0.033/100,000. The proportions of children younger than 15years, multibacillary cases, and cases with World Health Organization grade 2 disability were 1.3%, 90.3%, and 21.6%, respectively. A total of 2,219 leprosy cases were registered in China by the end of 2019, giving a prevalence rate of 0.158/100,000. Fifty-six counties had a prevalence rate of more than 1/100,000, and most of them were located in Southwest China. There were 31 reported relapse cases. Conclusion: The prevalence of leprosy has improved continuously throughout China, but the southwest region is still an area of concern.

Determining target populations for leprosy prophylactic interventions: a hotspot analysis in Indonesia

BackgroundLeprosy incidence remained at around 200,000 new cases globally for the last decade. Current strategies to reduce the number of new patients include early detection and providing post-exposure prophylaxis (PEP) to at-risk populations. Because leprosy is distributed unevenly, it is crucial to identify high-risk clusters of leprosy cases for targeting interventions. Geographic Information Systems (GIS) methodology can be used to optimize leprosy control activities by identifying clustering of leprosy cases and determining optimal target populations for PEP.MethodsThe geolocations of leprosy cases registered from 2014 to 2018 in Pasuruan and Pamekasan (Indonesia) were collected and tested for spatial autocorrelation with the Moran’s I statistic. We did a hotspot analysis using the Heatmap tool of QGIS to identify clusters of leprosy cases in both areas. Fifteen cluster settings were compared, varying the heatmap radius (i.e., 500 m, 1000 m, 1500 m, 2000 m, or 2500 m) and the density of clustering (low, moderate, and high). For each cluster setting, we calculated the number of cases in clusters, the size of the cluster (km2), and the total population targeted for PEP under various strategies.ResultsThe distribution of cases was more focused in Pasuruan (Moran’s I = 0.44) than in Pamekasan (0.27). The proportion of total cases within identified clusters increased with heatmap radius and ranged from 3% to almost 100% in both areas. The proportion of the population in clusters targeted for PEP decreased with heatmap radius from > 100% to 5% in high and from 88 to 3% in moderate and low density clusters. We have developed an example of a practical guideline to determine optimal cluster settings based on a given PEP strategy, distribution of cases, resources available, and proportion of population targeted for PEP.ConclusionPolicy and operational decisions related to leprosy control programs can be guided by a hotspot analysis which aid in identifying high-risk clusters and estimating the number of people targeted for prophylactic interventions.

Leprosy post-exposure prophylaxis with single-dose rifampicin (LPEP): an international feasibility programme

Innovative approaches are required for leprosy control to reduce cases and curb transmission of Mycobacterium leprae. Early case detection, contact screening, and chemoprophylaxis are the most promising tools. We aimed to generate evidence on the feasibility of integrating contact tracing and administration of single-dose rifampicin (SDR) into routine leprosy control activities. The leprosy post-exposure prophylaxis (LPEP) programme was an international, multicentre feasibility study implemented within the leprosy control programmes of Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Tanzania. LPEP explored the feasibility of combining three key interventions: systematically tracing contacts of individuals newly diagnosed with leprosy; screening the traced contacts for leprosy; and administering SDR to eligible contacts. Outcomes were assessed in terms of number of contacts traced, screened, and SDR administration rates. Between Jan 1, 2015, and Aug 1, 2019, LPEP enrolled 9170 index patients and listed 179 769 contacts, of whom 174 782 (97·2%) were successfully traced and screened. Of those screened, 22 854 (13·1%) were excluded from SDR mainly because of health reasons and age. Among those excluded, 810 were confirmed as new patients (46 per 10 000 contacts screened). Among the eligible screened contacts, 1182 (0·7%) refused prophylactic treatment with SDR. Overall, SDR was administered to 151 928 (86·9%) screened contacts. No serious adverse events were reported. Post-exposure prophylaxis with SDR is safe; can be integrated into different leprosy control programmes with minimal additional efforts once contact tracing has been established; and is generally well accepted by index patients, their contacts, and health-care workers. The programme has also invigorated local leprosy control through the availability of a prophylactic intervention; therefore, we recommend rolling out SDR in all settings where contact tracing and screening have been established. Novartis Foundation.

Predicting the impact of household contact and mass chemoprophylaxis on future new leprosy cases in South Tarawa, Kiribati: A modelling study.

BackgroundThe country of Kiribati is a small Pacific island nation which had a new case detection rate of 191 per 100,000 in 2016, and is one of the few countries yet to reach the WHO leprosy elimination goal. Chemoprophylaxis of household contacts of new cases, or to the whole population in a highly endemic areas have been found to be effective in reducing new case rates. This study investigated the potential impact of different chemoprophylaxis strategies on future cases in South Tarawa, the main population centre of Kiribati.MethodologyThe microsimulation model SIMCOLEP was calibrated to simulate the South Tarawa population and past leprosy control activities, and replicate annual new cases from 1989 to 2016. The impact of six different strategies for delivering one round of single dose rifampicin (SDR) chemoprophylaxis to household contacts of new cases and/or one or three rounds of SDR to the whole population was modelled from 2017 to 2030.Principal FindingsOur model predicted that continuing the existing control program of high levels of public awareness, passive case detection, and treatment with multidrug treatment would lead to a substantial reduction in cases but this was less effective than all modelled intervention scenarios. Mass chemoprophylaxis led to a faster initial decline in cases than household contact chemoprophylaxis alone, however the decline under the latter was sustained for longer. The greatest cumulative impact was for household contact chemoprophylaxis with three rounds of mass chemoprophylaxis at one-year intervals.ConclusionsThe results suggest that control of leprosy would be achieved most rapidly with a combination of intensive population-based and household chemoprophylaxis. These findings may be generalisable to other countries where crowding places social contacts as well as household contacts of cases at risk of developing leprosy.

Overlapping of new leprosy cases in household contact networks in two municipalities in North and Northeast Brazil, 2001-2014

The study aimed to analyze the magnitude and sociodemographic profile of leprosy cases linked to household contact networks with overlapping of the disease in two Brazilian municipalities (counties), one in the North and the other in the Northeast, from 2001 to 2014. This was a cross-sectional, descriptive, analytical study based on primary and secondary data from new leprosy cases in Picos, Piauí State, and Rolim de Moura, Rondônia State. "Overlapping" was defined as new cases with the occurrence of at least one more leprosy case in the individual's household contact network. Each household contact network consisted of the index case (first reported case), co-prevalent cases (contacts that became new cases), and household contacts of the index case. A total of 437 new cases treated by the INTEGRAHANS North-Northeast and Piauí projects were assessed, of which 287 (65.7%) were in Picos and 150 (34.3%) in Rolim de Moura. Of all the cases assessed, 129 (44.9%) in Picos and 98 (65.3%) in Rolim de Moura reported overlapping. There were proportionally more females in Rolim de Moura (n = 95, 63.3%) and males in Picos (n = 147, 51.2%); in the 41-60-year age bracket (Rolim de Moura n = 70, 46.7%; Picos n = 115, 40.1%); with elementary schooling (Rolim de Moura n = 80, 54%; Picos n = 125, 44.5%); and individuals living in the same household with up to 3 persons in Rolim de Moura (n = 105, 70%) and with more than 4 persons in Picos (n = 287, 100%). Overlapping of leprosy cases in household contact networks was considerably high in the contexts analyzed here, displaying aspects of expanded vulnerability. This perspective should be considered and integrated into leprosy surveillance and control activities.

The Leprosy Post-Exposure Prophylaxis (LPEP) programme: update and interim analysis.

Innovative approaches are required to further enhance leprosy control, reduce the number of people developing leprosy, and curb transmission. Early case detection, contact screening, and chemoprophylaxis currently is the most promising approach to achieve this goal. The Leprosy Post-Exposure Prophylaxis (LPEP) programme generates evidence on the feasibility of integrating contact tracing and single-dose rifampicin (SDR) administration into routine leprosy control activities in different settings. The LPEP programme is implemented within the leprosy control programmes of Brazil, Cambodia, India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. Focus is on three key interventions: tracing the contacts of newly diagnosed leprosy patients; screening the contacts for leprosy; and administering SDR to eligible contacts. Country-specific protocol adaptations refer to contact definition, minimal age for SDR, and staff involved. Central coordination, detailed documentation and rigorous supervision ensure quality evidence. Around 2 years of field work had been completed in seven countries by July 2017. The 5,941 enrolled index patients (89·4% of the registered) identified a total of 123,311 contacts, of which 99·1% were traced and screened. Among them, 406 new leprosy patients were identified (329/100,000), and 10,883 (8·9%) were excluded from SDR for various reasons. Also, 785 contacts (0·7%) refused the prophylactic treatment with SDR. Overall, SDR was administered to 89·0% of the listed contacts. Post-exposure prophylaxis with SDR is safe; can be integrated into the routines of different leprosy control programmes; and is generally well accepted by index patients, their contacts and the health workforce. The programme has also invigorated local leprosy control.

Performance of general health workers in leprosy control activities at public health facilities in Amhara and Oromia States, Ethiopia.

BackgroundLeprosy is a chronic infectious disease of public health importance and one of the leading causes of permanent physical disability. Nevertheless, the drop in prevalence following multidrug therapy has resulted in the neglect of leprosy. The annual incidence of leprosy has remained the same in Ethiopia since decades with more than 76 % of the reported new cases coming from Oromia and Amhara Regional States. This study was aimed to assess the knowledge, attitude and skill of general health workers in leprosy control activities at public health facilities in Oromia and Amhara Regional States.MethodsA cross-sectional study was conducted from September 2011 to February 2012 at different public health facilities in selected eight zones in Oromia and Amhara Regional States. A multistage sampling method was used to obtain representative samples. High and low endemic zones for leprosy were included in the study in both regional states. Data were collected from general health workers through a structured self-administered questionnaire and at on-site assessment of their performance. Baseline socio-demographic data, health workers’ attitude towards leprosy and their knowledge and skill in the management of leprosy were assessed. Bloom’s cut off point was used to describe the knowledge and practical skills of the respondents while Likert’s scale was used for attitude assessment.ResultA total of 601 general health workers responsible for leprosy control activities at public health facilities were included in knowledge and attitude assessment and 83 of them were subjected to practical evaluation, with on-site observation of how they handle leprosy patients. These included medical doctors (4 %), health officers and nurses with Bachelor degree in Science (27 %), clinical nurses with diploma (66 %) and health assistants (2.8 %). The median age of the respondents was 26.0 years and females made up of 45 %. Generally the knowledge and skills of the respondents were found to be poor while attitude towards leprosy was positive for the majority of the respondents. The result showed that 519 (86.3 %) had poor knowledge. Overall 155 (25.8 %) of the respondents had positive attitude towards leprosy while 205 (34.1 %) had intermediate (mixed) attitude and 241 (40.1 %) had negative attitude to the disease. Among 83 respondents assessed for diagnosis of leprosy only 15(18.0 %) diagnosed leprosy correctly. Variation in knowledge and attitude indicated a significant difference (p < 0.05) among different health institutions, professions, gender, in-service training and years of experience.ConclusionThe current finding underlines that although leprosy control activities are integrated to the general health services in the country, the knowledge and skills of leprosy diagnosis, treatment and management by health workers was unsatisfactory. Hence, attention should be given to develop training strategies that can improve health worker knowledge and promote better leprosy management at public health facilities. This could be achieved through pre-service and in-service training and giving adequate emphasis to leprosy related practical work and continuous follow- up.

A historical overview of leprosy epidemiology and control activities in Amazonas, Brazil.

Leprosy is an ancient infectious disease caused by Mycobacterium leprae. According to comparative genomics studies, this disease originated in Eastern Africa or the Near East and spread with successive human migrations. The Europeans and North Africans introduced leprosy into West Africa and the Americas within the past 500 years. In Brazil, this disease arrived with the colonizers who disembarked at the first colonies, Rio de Janeiro, Salvador and Recife, at the end of the sixteenth century, after which it was spread to the other states. In 1854, the first leprosy cases were identified in State of Amazonas in the north of Brazil. The increasing number of leprosy cases and the need for treatment and disease control led to the creation of places to isolate patients, known as leprosaria. One of them, Colonia Antônio Aleixo was built in Amazonas in 1956 according to the most advanced recommendations for isolation at that time and was deactivated in 1979. The history of the Alfredo da Matta Center (AMC), which was the first leprosy dispensary created in 1955, parallels the history of leprosy in the state. Over the years, the AMC has become one of the best training centers for leprosy, general dermatology and sexually transmitted diseases in Brazil. In addition to being responsible for leprosy control programs in the state, the AMC has carried out training programs on leprosy diagnosis and treatment for health professionals in Manaus and other municipalities of the state, aiming to increase the coverage of leprosy control activities. This paper provides a historical overview of leprosy in State of Amazonas, which is an endemic state in Brazil.

Leprosy Scenario at a Tertiary Level Hospital in Delhi: A 5-year Retrospective Study.

Background:Leprosy has been officially eliminated from India since December, 2005; still, there are districts and blocks reporting high prevalence indicating ongoing transmission. The present study aimed at determining the current clinical profile of leprosy from a tertiary level hospital in Delhi.Materials and Methods:A retrospective, record-based study was carried out on patients diagnosed and registered in the leprosy clinic of a tertiary level teaching hospital in East district of Delhi (April 2007 to March 2012). Data regarding demographic details, clinical features, treatment started and complications was analyzed.Results:A total of 849 patients were registered over a 5-year period, with M: F ratio of 2.3:1. 9.3% were children (≤14 years). 54.3% patients were immigrants from adjoining states. Multibacillary leprosy was the most common clinical type (86.9%). Borderline tuberculoid leprosy was the most frequent morphologic type, seen in 56.3% followed by borderline-borderline (1.5%), borderline lepromatous (24.9%), lepromatous leprosy (8.1%), pure neuritic (8.1%), histoid and indeterminate leprosy (0.5% each). 37.4% patients presented in reaction (Type I in 30.4% cases and Type II in 7% cases). WHO grade II deformities were diagnosed in 37.9% with claw hand being the most common paralytic deformity (23.3% cases).Conclusion:Our study offers insight into the current status of the disease in an area of otherwise low prevalence. It is seen that despite statistical elimination, multibacillary disease, leprosy reactions and deformities are commonly seen as presenting manifestations, in contrast to national projected trends. Delhi's unique demography with a high degree of migrant workers, presenting to our center (near border location) could be a possible contributing factor towards these aberrations. It highlights the need for continuation of targeted leprosy control activities and active case detection.

Childhood leprosy situation in Myanmar in 2012

Leprosy had been a public health problem in Myanmar, for many years. The Government of Myanmar at various times, with the expertise and advice of the World Health Organization (WHO) and INGOs, had been fighting against the disease. As the country had made a strong and clear decision to eliminate the leprosy as soon as possible, many bodies both internal and external came to join hand in hand to accelerate the efforts for leprosy elimination. Myanmar achieved leprosy elimination in February 2003 and this fact had been officially declared at the Meeting of Third Global Alliance for Elimination of Leprosy held in Yangon. After achieving the goal of elimination, sustaining leprosy control services is still necessary for further reducing the leprosy burden. The WHO Strategy for Further Reducing the Leprosy Burden and Sustaining Leprosy Control Activities (2006-2010) and Enhanced Global Strategy for Further Reducing the Disease Burden Due to Leprosy (2011-2015) have been widely endorsed. Leprosy services have been integrated into the general health services and need for an effective referral system, as a part of integrated programme, has been recognised. Our challenge is to sustain the quality of leprosy services and to ensure that all leprosy affected people, wherever they live, have an equal opportunity to be diagnosed and treated by competent health workers without unnecessary delays. Among the challenges, we are facing the yearly detection of child leprosy cases and Grade-2 disability cases among new cases; 3013 new leprosy cases were detected in 2012. Among the new cases, 155 were child leprosy cases and 503 cases had Grade-2 disability at diagnosis. Out of the 155 new child leprosy cases, 33 cases had Grade-2 disability. Therefore, we studied the cross sectional analysis of new child leprosy cases with Grade-2 disability during 2012 in Myanmar.

Informed consent in Leprosy Studies

The control of leprosy continues to be an international health problem with a need to study and conduct research in many areas of leprosy control from treatment, to prevention of disabilities, to the social determinants of the disease. The ‘Enhanced Global Strategy for 2011 – 2015’ to further reduce the leprosy disease burden has been adopted and is being implemented by national leprosy programmes in countries where the disease is endemic. The strategy aims to reduce the rate of new cases with Grade-2 disabilities (visible disabilities) worldwide by $35% by the end of 2015. The WHO document indicates that the target is expected to help national programmes sustain their leprosy control activities and to monitor progress towards further reducing the disease burden. Within this strategy there are many research questions. Leprosy research requires different disciplines perspective and tools, from immunology, with a focus on cells, to anthropology with a focus on individuals, to epidemiology with a focus on populations and finally to policy with its focus on power and process. The common factor in all these disciplines is that they need people with leprosy, their families, their communities and the health care workers in the health systems, to agree to be involved in the research. If a person is to be involved in a research study, then their consent needs to be sought and acquired. A focus on the individual is essential and that is why the focus for the ethics of research is on protecting the rights of the individual study subject.

Analysis of newly detected leprosy in Sohag Governorate, Upper Egypt, 2004–2008

Leprosy is a chronic and complex infectious illness; the new-case detection rate is better than prevalence as an indicator of disease trends. This study presents an analysis of pattern of new cases of leprosy detected annually from 2004 to 2008 in Sohag Governorate, Upper Egypt. Data about patients with newly diagnosed leprosy were collected from Sohag leprosy hospital, the main referral centre in the governorate. Case detection rates (CDR) were calculated for each year by dividing the newly diagnosed cases by mid-year populations for the same year. 587 patients were newly diagnosed between 2004 and 2008. The mean age of patients at diagnosis was 34 years, 62% were males, and 11% were children below 15 years of age. The overall leprosy case detection rate was 3-1/100,000 population and it decreased from 3.4/100,000 population in 2004 to 2.8/100,000 population in 2008. Ninety three percent were classified as multibacillary, and 20.4% had Grade 2 disability at diagnosis. Leprosy remains a health problem in Sohag Governorate. It is possible that new cases are being detected late owing to inadequate community awareness of the disease. Leprosy control activities should be provided in primary health care units in order to detect new cases, and continued surveillance is required to detect relapses and to ensure good patient compliance with treatment.

Clusters of leprosy transmission and of late diagnosis in a highly endemic area in Brazil: focus on different spatial analysis approaches

The Brazilian National Hansen's Disease Control Program recently identified clusters with high disease transmission. Herein, we present different spatial analytical approaches to define highly vulnerable areas in one of these clusters. The study area included 373 municipalities in the four Brazilian states Maranhão, Pará, Tocantins and Piauí. Spatial analysis was based on municipalities as the observation unit, considering the following disease indicators: (i) rate of new cases/100,000 population, (ii) rate of cases <15 years/100,000 population, (iii) new cases with grade-2 disability/100,000 population and (iv) proportion of new cases with grade-2 disabilities. We performed descriptive spatial analysis, local empirical Bayesian analysis and spatial scan statistic. A total of 254 (68.0%) municipalities were classified as hyperendemic (mean annual detection rates >40 cases/100,000 inhabitants). There was a concentration of municipalities with higher detection rates in Pará and in the center of Maranhão. Spatial scan statistic identified 23 likely clusters of new leprosy case detection rates, most of them localized in these two states. These clusters included only 32% of the total population, but 55.4% of new leprosy cases. We also identified 16 significant clusters for the detection rate <15 years and 11 likely clusters of new cases with grade-2. Several clusters of new cases with grade-2/population overlap with those of new cases detection and detection of children <15 years of age. The proportion of new cases with grade-2 did not reveal any significant clusters. Several municipality clusters for high leprosy transmission and late diagnosis were identified in an endemic area using different statistical approaches. Spatial scan statistic is adequate to validate and confirm high-risk leprosy areas for transmission and late diagnosis, identified using descriptive spatial analysis and using local empirical Bayesian method. National and State leprosy control programs urgently need to intensify control actions in these highly vulnerable municipalities.