Post-elimination Era Research Articles

Current scenario of leprosy in post elimination era at a tertiary care hospital in central India

Background: Leprosy is a chronic granulomatous infectious disease caused by Mycobacterium leprae primarily affecting the skin and peripheral nerves. Though India announced statistical elimination of leprosy as public health problem under the National Leprosy Eradication Programme in December 2005, still wide variations exist in prevalence rates of this disease across the country. Objectives: Of the study were to determine the pattern, occurrence and trends of smear positive leprosy cases at Government medical college, Akola. Materials and Methods: This is a retrospective study conducted from January 2018 to February 2020. All patients suspected of leprosy were confirmed by slit skin smear examination. Record details of age, type and duration of disease, deformity status were noted. Results: Total 520 clinically suspected were examined. 175 were diagnosed smear positive foe acid fast bacilli. Males outnumbered females. Smear positivity was highest in 21- 40 years age group. Multibacillary cases were 103(58.85%) and paucibacillary were 72(41.14%). Interpretation and Conclusion: Present study shows that despite statistical elimination, leprosy still continues to be a challenge. Approaches like destigmatising the disease, family counseling, integrating leprosy care into general health care systems, developing newer diagnostic and epidemiological tools, chemoprophylactic regimens and vaccines are needed to develop eradication strategy that can reduce the burden of leprosy in India. Keywords: Leprosy, Acid fast bacilli, Smear positive cases.

A clinical study of new cases of Hansen’s disease at a tertiary health care centre in post elimination era

<p><strong>Background</strong>: Leprosy, in 2016, globally a total of 214,783 new cases were reported over half of them were from India (135,485) alone. However, 16 other countries with pockets of high endemicity were reported. On the other hand, actual numbers of people affected by the disease is likely to be far higher than statistics show as there still prevails lack of awareness about the disease, lack of skills of general health staff in leprosy diagnosis, inadequate active case findings, lack of inclusion of cases from private sector and presence of high stigma in the community. Aims and objectives were to study the number of increasing new cases of Hansen’s disease in post elimination era.</p><p><strong>Methods</strong><strong>:</strong> A prospective observational study of number of new cases of leprosy presented at a department of DVL, BMCH, Chitradurga, Karnataka, from 2017 April-2018 September. A total of 91 cases were detected.</p><p><strong>Results:</strong> Series of 91 cases were detected, and based on WHO classification were classified as multibacillary (MB)-72 cases and paucibacillary (PB)-19 cases. The maximum number of cases were detected between 20-29 years of age. The male to female ratio was 1.2:1. 46 (50.54%) cases were diagnosed to have borderline tuberculoid (BT). Patients mainly belonged to low socioeconomic status (89.1%). Deformities were seen in 21 (23.07%)) cases. 7 patients presented with type-I reaction and 13 patients with type-II reactions.</p><p><strong>Conclusions:</strong> Even with MB-MDT and monitoring, some high endemic pockets of leprosy may continue to persists in India. Every year new cases are increasing and causing morbidity from neglected cases. We should not be complacent at this stage because it may become a serious health problem again.</p>

Visible disability as a presenting feature of leprosy: a rare but real concern in post-elimination phase in India

<p class="abstract">Leprosy (Hansen's disease) is a chronic infectious disease caused by <em>Mycobacterium leprae</em>, affecting mainly peripheral nerves and skin. Delayed diagnosis contributes to sensory-motor impairment leading to deformity and disability, thereby imposing a major impact on the physical, social, economic and psychological domains of the quality of life of affected individuals. Deformities and disabilities are largely preventable complications associated with tremendous social stigma and discrimination, assuming public health significance. India declared elimination of leprosy more than a decade and half ago in 2005. Hence, grade 2 disability is expected to be a rare manifestation in the post-elimination era. However, to the contrary, the proportion of new leprosy patients with visible disability recorded in India exceeds the global rate. Herein we report a middle-aged female presenting with saddle nose, bilateral fixed ulnar and mobile median claw hands (grade 2 disability) with multiple trophic ulcers. This case emphasizes that clinical suspicion after careful examination of skin and neural manifestations is of utmost importance for the early diagnosis of leprosy. Timely self-reporting and management with WHO-multi drug therapy (MDT) remains the key to minimize the risk of deformity and disability. Above all, it is essential to create awareness amongst the community regarding prompt recognition of symptoms and easy access to appropriate care along with intensified efforts to address the associated stigma.</p>

Evaluation of Loopamp™ Leishmania Detection Kit and Leishmania Antigen ELISA for Post-Elimination Detection and Management of Visceral Leishmaniasis in Bangladesh

With reduced prevalence of visceral leishmaniasis (VL) in the Indian subcontinent (ISC), direct and field deployable diagnostic tests are needed to implement an effective diagnostic and surveillance algorithm for post-elimination VL control. In this regard, here we investigated the diagnostic efficacies of a loop-mediated isothermal amplification (LAMP) assay (Loopamp™ Leishmania Detection Kit, Eiken Chemical CO., Ltd, Japan), a real-time quantitative PCR assay (qPCR) and the Leishmania antigen ELISA (CLIN-TECH, UK) with different sampling techniques and evaluated their prospect to incorporate into post-elimination VL control strategies. Eighty clinically and rK39 rapid diagnostic test confirmed VL cases and 80 endemic healthy controls were enrolled in the study. Peripheral blood and dried blood spots (DBS) were collected from all the participants at the time of diagnosis. DNA was extracted from whole blood (WB) and DBS via silica columns (QIAGEN) and boil & spin (B&S) methods and tested with qPCR and Loopamp. Urine was collected from all participants at the time of diagnosis and was directly subjected to the Leishmania antigen ELISA. 41 patients were followed up and urine samples were collected at day 30 and day 180 after treatment and ELISA was performed. The sensitivities of the Loopamp-WB(B&S) and Loopamp-WB(QIA) were 96.2% (95% CI 89·43-99·22) and 95% (95% CI 87·69-98·62) respectively. The sensitivity of Loopamp-DBS(QIA) was 85% (95% CI 75·26- 92·00). The sensitivities of the qPCR-WB(QIA) and qPCR-DBS(QIA) were 93.8% (95% CI 86·01-97·94) and 72.5% (95% CI 61·38-81·90) respectively. The specificity of all molecular assays was 100%. The sensitivity and specificity of the Leishmania antigen ELISA were 97.5% (95% CI 91·47-99·70) and 91.95% (95% CI 84·12-96·70) respectively. The Leishmania antigen ELISA depicted clinical cure at day 180 in all the followed-up cases. Efficacy and sustainability identify the Loopamp-WB(B&S) and the Leishmania antigen ELISA as promising and minimally invasive VL diagnostic tools to support VL diagnostic and surveillance activities respectively in the post-elimination era.

Leprosy in the post elimination era: a retrospective descriptive study from district Kathua, Jammu and Kashmir

Background: Leprosy is often referred to as the oldest disease known to man. Leprosy as a social disease has been a major public health problem because of the social stigma and ignorance attached to it. India achieved elimination status for leprosy in 2005; however, the reported prevalence continues to be high in some of the states. Leprosy understood as God’s retribution, has been present since the colonial times. Stigma attached to leprosy is typically a social process, experienced or anticipated, characterized by exclusion, rejection, blame or devaluation that result from experience, perception or reasonable anticipation of an adverse social judgment about a person or group. Objective was to study the demographic and epidemiological features of leprosy in the post-elimination era.Methods: A retrospective descriptive study was conducted from July 2019 to September 2019. Case records of newly diagnosed leprosy patients were included in the study. The secondary data was collected from district leprosy society Kathua retrospectively for a period of nine and half years (from April 2010 to September 2019). Data was entered in Microsoft excel and Descriptive statistics were analysed.Results: In our study, 154 total leprosy cases were registered from April 2010 to September 2019. Among the demographic details of leprosy cases, maximum number of cases were in the age group of 31-40 years (38.31%) and childhood leprosy cases were 1.94%. Majority of cases were females as compared to males. Out of 154 cases, 35 cases were outsiders registered in the Kathua district. The treatment completion rate was 100%, no defaulter cases were reported from the past decade.Conclusions: Leprosy continues to be a communicable disease of concern in the post-elimination era. This alarms the need to strengthen contact screening, early case detection, referral activities and even more focus on the pediatric population to sustain elimination.

Molecular Epidemiology of Measles in California, United States—2019

In 2019, the United States (US) experienced the highest number of measles importations and cases in the postelimination era. More than a quarter of imported cases entered the US through California. Measles surveillance efforts in California resulted in the identification of 26 importations, 6 outbreaks, and 72 cases in 2019. Only genotype B3 and D8 measles strains were detected. Genotype-specific differences were noted in the incidence of vaccine failures, hospitalizations, and severe complications among cases. A targeted whole genome sequencing approach provided higher-resolution discrimination between epidemiologically linked and sporadically introduced strains than conventional N450 sequencing. Our report underscores the importance of ensuring appropriate measles vaccination status, especially prior to international travel to measles-endemic regions, and highlights the value of a strong measles surveillance system in minimizing outbreaks and preserving measles elimination status in the US.

Factors associated with measles resurgence in the United States in the post-elimination era

There have been growing concerns of a potential re-establishment of measles transmission in the United States (US) in the years to come. This study aims to explore potential factors underlying the resurgence of measles in the US by objectively assessing the associations between annual incidence rates (AIR), case importation, vaccination status and disease outbreaks. Data on measles transmission between January 1st, 2001 and December 31st, 2019 were obtained from the national centres for disease control and prevention (CDC) surveillance databases and other published reports. Changes in incidence rates over time were assessed by binomial regression models. Of the 3874 cases of measles in the US over the study period, 3506 (90.5%, 95% CI: 89.5–91.4) occurred in US residents. The AIR per million population in US residents over this period was 0.60 (95% CI: 0.59–0.61), with an overall significant increase over time (p = 0.011). The median percentage of imported and vaccinated cases were 36% [17.9–46.6] and 15% [12.1–23.2] respectively. There was a significant decrease in the percentage of imported cases (p < 0.001) but not of vaccinated cases (p = 0.159) over time. There was a moderate and weak negative correlation between the AIR and the percentage of imported and vaccinated cases respectively (r = –0.59 and r = –0.27 respectively). On multiple linear regression there was a significant linear association between the AIR and the number of outbreaks (p = 0.003) but not with the percentage of imported cases (p = 0.436) and vaccinated cases (p = 0.692), R2 = 0.73. Strong negative and positive correlations were seen between the number of outbreaks and the percentage of imported cases (r = –0.61) and the of number states affected (r = 0.88) respectively. Despite the overall reduction in the percentage of imported cases of measles over the past two decades, pockets of internal transmission of the disease following importation via increasing number of outbreaks in unvaccinated subpopulations, reinforced by vaccine hesitancy, account for the sustained increase in measles incidence rates in the US. Controlling indigenous transmission through efficient vaccination coverage in at-risk subpopulations and among international US travellers, improved disease surveillance and rapid outbreak containment are essential in curbing the measles resurgence.

Temporal-spatial distribution characteristics of leprosy: A new challenge for leprosy prevention and control in Zhejiang, China.

BackgroundAfter the elimination of leprosy in 1995, there were 10–30 newly detected leprosy cases every year in Zhejiang Province, and the epidemiological characteristics of the newly detected leprosy cases have changed. While most of the newly detected cases came from other provinces in China, not Zhejiang, it brought a new challenge for leprosy prevention and control in post- elimination era in Zhejiang, China. This study was aimed to understand the temporal-spatial distribution characteristics of newly detected leprosy cases, and provide the scientific rationales for the development of leprosy control strategy.MethodsData on the demographic of Zhejiang Province from 2011 to 2019 were obtained from the China Information System for Disease Control and Prevention, and the epidemiological data on leprosy cases newly detected in Zhejiang Province from 2011 to 2019 were obtained from the LEPROSY MANAGEMANT INFORMATION SYSTEM IN CHINA (LEPMIS), and temporal-spatial distributions were described. The geographic information system software—ArcGIS 10.4 was used to draw the statistical maps, and Geoda 1.14.0 was used for local spatial autocorrelation analysis (local Getis coefficient method). Ridley-Jopling classification was used to classify the clinical types into I, TT, BT, BB, BL or LL. Two-group classification system developed by the World Health Organization (WHO) was used and cases were classified into multibacillary (MB) type or paucibacillary (PB) type.ResultsA total of 167 leprosy cases were reported in Zhejiang Province during 2011–2019, including 107 cases in males and 60 in females. The mean age at diagnosis was 37.99±14.81 years, and 94.01% of the cases were detected through the examination at skin-clinics. The number of workers, MB cases, G2D cases were 81 (48.50%), 159 (94.01%), 24 (14.37%) respectively, and the rate of early detection increased from 45.16% in 2011 to 90.91% in 2019. Leprosy cases were reported in all the prefectures of Zhejiang except Zhoushan City. The cases in local population accounted for 23.35% (39 cases), and the cases in floating population (especially coming from high epidemic provinces in China) accounted for 76.65% (128 cases). The annual number of newly detected cases showed a decreasing trend, from 31 cases in 2011 to 11 in 2019. Time of the floating population living in Zhejiang Province ranged from several months to more than 10 years. The annual proportion of new cases with G2D declined from 22.58% in 2011 to 9.09% in 2019. The results of local indicators of autocorrelation (LISA) analysis showed that the high-high areas were mainly concentrated in the middle and northeast of Zhejiang Province, while the low-low areas were in the east and southwest.ConclusionA few scattered cases still can be seen in post-elimination era, and there was a spatial clustering of the newly detected leprosy cases in Zhejiang Province. Most of the cases in Zhejiang Province were from other high epidemic provinces in China, which brought a new challenge for leprosy control and prevention in post- elimination era in Zhejiang, and it is also necessary to strengthen the early detection and standard management of the leprosy cases in floating population in Zhejiang.

A Case of Histoid Hansens Mimicking as Neurofibroma in Presentation in a Post Elimination Era

Histoid leprosy is an unusual leprosy variety generally following the failure of therapy. It occurs de novo from time to time with a history of insufficient or improper treatment. In this case report a case of such a presentation of histoid leprosy mimicking as neurofibroma in 25-year-old male patient of Kalaburagi region in post elimination era is presented. The frequency of leprosy of 0.6210000 had been recorded in March 2017 National Leprosy Eradication programme NELP.nbsp

Health Burden of Hansen's Disease in Central India: A 4-Year Retrospective Study.

Background:Despite the implementation of multidrug therapy by WHO to treat Hansen's disease (HD), new case detection rates are still high indicating active transmission.Aims and Objectives:To study the clinical profile of HD in central India along with its epidemiological characteristics.Materials and Methods:Medical records of clinically diagnosed Hansen's patients were recruited retrospectively during January 2015 to December 2018. Case records were evaluated with respect to demographic, clinical, histopathological, and bacteriological investigations, development of reaction, and deformities. Patients were classified based on Ridley Jopling classification and treated accordingly. Statistical analysis was done using proportion, mean, and percentage.Results:A total of 400 new patients were enrolled and males outnumbered females. Maximum cases, 115 (28.75%), were in the age group of 31–40 years. Sixteen (4%) cases belonged to the pediatric age (less than 18 years) group. Most common clinical spectrum was borderline lepromatous (n = 156, 39%) followed by lepromatous HD (n = 120, 30%). Eleven patients had pure neuritic HD and nine had histoid HD. Grade 2 deformity was found in 52 and grade 1 deformity was found in 16 patients. Most common lepra reaction was type 2 lepra reaction (n = 112, 28%). Thirteen (3.25%) patients were of relapse of HD among which maximum eight were BL HD followed by LL HD three (0.75%) and TT HD two (0.5%).Conclusion:Early diagnosis is very important for timely and proper implementation of treatment which will prevent sequelae and physical disabilities that can have an impact on the individual's social and working life, which are responsible for stigma and prejudice regarding the disease. Detection of this huge number of cases signifies a high burden of HD in this area even in the post elimination era.

Understanding the Resurgence of an Eliminated Disease: Spatial, Attitudinal, and Regulatory Factors Underlying Measles Outbreaks in the Post-Elimination Era

Understanding the Resurgence of an Eliminated Disease: Spatial, Attitudinal, and Regulatory Factors Underlying Measles Outbreaks in the Post-Elimination Era

Profiles of Pediatric Leprosy: A Report from a University Hospital of Nepal in the Post-Elimination Era.

Because pediatric leprosy strongly indicates continuous disease transmission in the community, knowing the profiles of pediatric leprosy is of great value for a leprosy-free world. We conducted this study to assess the clinical profiles of pediatric leprosy in Nepal. This retrospective study analyzed the 7-year record from 2011 to 2017. There were a total of 68 pediatric leprosy cases. Male (63.2%) cases outnumbered female cases. The minimum age of the leprosy-affected children was 6 years, with the mean age 12.17 (±1.95) years. Contact history was present in 26 (38.2%) children. Most of them (83.8%) had positive slit-skin smear. Lepra reaction was present in 14.7%. Nine had disability, with 4/9 (44.4%) of them having grade 2 disability. More than two-thirds (70.6%) were multi-bacillary cases. Some (2.9%) even had lepromatous leprosy. Leprosy continues to be a disease of concern in the post-elimination era even in the pediatric population.

Surveillance on schistosomiasis in five provincial-level administrative divisions of the People\u2019s Republic of China in the post-elimination era

BackgroundThe People’s Republic of China (P. R. China) has made significant progress on schistosomiasis control. Among the 12 provincial-level administrative divisions (PLADs) with schistosomiasis endemic in P. R. China, Guangdong, Shanghai, Fujian, Guangxi and Zhejiang PLADs (following as five PLADs) had successively eliminated schistosomiasis during 1985–1995. However, consolidation of the schistosomiasis elimination in these five PLADs remains challenging. In the current study, we sought to understand the epidemic situation in these post-elimination areas and their surveillance capabilities on schistosomiasis.MethodsAnnual data reflecting the interventions and surveillance on human beings, cattle and snails based on county level from 2005 to 2016 were collected through the national schistosomiasis reporting system and the data were analyzed to understand the epidemic status of schistosomiasis in the five PLADs. A standardized score sheet was designed to assess the surveillance capacity for schistosomiasis of selected disease control agencies in five PLADs and ten counties. Assessment on surveillance capacity including schistosomiasis diagnostic skills, identification of snails’ living and infection status and knowledge about schistosomiasis and its control were made. Descriptive analysis was used to analyze the epidemic status and evaluation results on surveillance capacities.ResultsThe assessments showed that no local cases in humans and cattle or infected snail were found in these five PLADs since 2005. However, from 2005 to 2016, a total of 221 imported cases were detected in Zhejiang, Shanghai and Fujian, and 11.98 hm2 of new snail habitats were found in Zhejiang, Shanghai and Guangxi. In addition, snail infestation reoccurred in 247.55 hm2 of former snail habitats since 2011. For the surveillance capacity assessment, the accuracy rate of IHA and MHT were 100 and 89.3%, respectively. All participants could judge the living status of snails accurately and 98.1% on the infection status of snails. The accuracy rate of the questionnaire survey was 98.0%.ConclusionsElimination of schistosomiasis was consolidated successfully in five PLADs of P. R. China due to effective and strong post-elimination surveillance. Comprehensive consolidation strategies should be focused on the elimination of residual snails and the prevention of imported infection sources to consolidate the achievements of schistosomiasis control.

Delayed diagnosis and ongoing transmission of leprosy in the post-elimination era in Boru Meda hospital, Ethiopia.

Following the recommendation of the Global Leprosy Strategy, Ethiopia targeted to reduce the incidence of new leprosy cases, and the proportion with severe disability (grade 2) from 13.6% in 2016 to < 1% in 2020. This study assessed the clinical profile of new leprosy cases and the sequelae of previously treated ones 20 years after leprosy was eliminated as a public health problem in the country. Hospital based cross sectional study was conducted by reviewing the medical records of all leprosy patients seen at the dermatology clinic of Boru Meda Hospital from August to December 2018.The data were captured using a standard data collection form. Over the study period, 57 (27.4%) new cases and 151 (72.6%) previously treated cases were seen.The median age was 44 years (interquartile range 32-57). Among the newly diagnosed cases, two were under the age of 15 years , 51 (89.5%) were multibacillary and 34 (59.6%) had grade 2 disability. This included visual impairment in 10 (17.5%) and neurological complications in 44 (77.2%). Of the 151 previously treated cases, 104 (68.9%) presented with disabilities, including 97 (64.2%) with grade 2. Amongst previously treated cases, 130 (86.1%) had neurological complications. In addition, 53 (35.1%) had vision impairment. This study showed evidence of ongoing leprosy transmission and delayed diagnosis in the country. This calls for operational research to determine the underlying reasons and provide ways forward. At the same time, the high burden of disabilities in previously treated cases should be addressed.

Clinico-pathological study of cases of histoid leprosy

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Rare variants of leprosy pose a diagnostic challenge and histoid leprosy is one such form of disease with unique clinical and histopathological features. The objective of the study was to study clinical and histopathological features of histoid leprosy.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A prospective observational study was conducted at M. R. Medical College and Basveshwar teaching and general hospital, Kalaburagi from July 2018 to October 2019. Newly diagnosed and histologically proven cases were included.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Histologically confirmed histoid leprosy accounted for 8 cases (7 males and 1 female). Mean age of the patients was 44.5 years. Patients presented with papules, plaques and nodules over an apparently normal skin. Bacterial index ranged from 4+ to 6+ according to Ridley index. Histopathology showed circumscribed lesion with free sub-epidermal grenz zone and spindle shaped cells.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; As bacillary load is very high in these patients, they can form a potential reservoir of infection in the community especially in post leprosy elimination era.&lt;/p&gt;

Elephantiasis nostras verrucosa secondary to leprous lymphadenopathy; a case report

Leprosy has earned the status of ‘great imitator’ considering its ability to present in wide array of manifestations. Typical neuro-dermatological features are easy to recognize but uncommon presentations frequently delay the diagnosis. Here we report a 60-years-old lady presenting with elephantiasis nostras verrucosa secondary to lepromatous leprosy. In the post elimination era, it is important to have a high index of suspicion to prevent delay in diagnosis.

Molecular detection of Mycobacterium leprae using RLEP-PCR in post elimination era of leprosy.

Leprosy is considered as a contagious disease and is still a health problem in several countries including India. Diagnosis of leprosy is based either on clinical findings or on acid fast bacilli staining. Due to low sensitivity of acid fast bacilli staining most of the leprosy cases were remained undetected. The present study aims to assess the efficacy of RLEP-PCR in the field condition where majority of the patients are acid fast bacilli negative and have early disease. A total of 80 suspected leprosy cases were recruited. Slit skin smear samples were taken for microscopy and molecular experimentation. DNA was extracted and RLEP-PCR was executed for all the 80 samples. To establish the statistical correlation χ2 test and Fisher's exact test were made. To elucidate the sensitivity of the test Receiver Operating Characteristic (ROC) was drawn. These 80 leprosy patients comprised of 38 paucibacillary and 42 multibacillary leprosy cases. Of 80 leprosy patients 18 (22.5%) were AFB positive while 53 (66.25%) leprosy cases were RLEP-PCR positive. The results of test of significance (P=0.0001) and Cohen's kappa coefficient(κ) (0.614) indicated that the RLEP-PCR is a better diagnostic tool over AFB microscopy in case detection of leprosy. From the findings we concluded that RLEP-PCR could be used for the definitive detection of leprosy cases in accordance with the clinical findings in the field condition in the post elimination era of leprosy.

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

BackgroundA few new leprosy cases still can be seen in Shandong province after elimination. In post-elimination era, government commitments dwindled and active case-finding activities were seldom done. Most of the cases were detected by passive modes and advanced cases with longer delay and visible disability were common.Materials and methodsComprehensive measures including health promotion, personnel training, reward-offering, symptom surveillance and a powerful referral center were implemented in the past decade. The diagnosis of leprosy was mainly based on three cardinal clinical signs. Two-group classification system developed by the WHO was used and cases were classified into multibacillary (MB) type or paucibacillary (PB) type. Cases detected during period 2007–2017 were analyzed and associated factors of grade 2 disability (G2D) were explored.Results231 new leprosy cases detected during 2007–2017 were analyzed. The mean age at diagnosis is 51.7±16.0 years and the number of males, peasants, illiterates, MB cases, G2D cases and immigrants were 130(56.3%), 221(95.7%), 73(31.6%), 184(79.7%), 92(39.8%) and 40(17.3%) respectively. 181(78.4%) cases were reported by skin clinics and 152 (65.8%) cases came from formerly high endemic counties/districts. The annual number of new cases showed a decreasing trend, from 42 cases in 2008 to 13 cases in 2017. 92 (39.8%) cases presented with G2D at diagnosis. The annual proportion of new cases with G2D declined from 50% in 2008 to 23% in 2017. PB type (OR = 2.76, 95% CI, 1.43–5.32), >12 months of patient delay (OR = 2.40, 95% CI, 1.38–4.19), >24 months of total delay (OR = 4.35, 95% CI, 2.33–8.11), detected by non skin-clinic (OR = 3.21, 95% CI, 1.68–6.14), known infectious source (OR = 1.77, 95% CI, 1.01–3.12) were associated with G2D.ConclusionA few scattered cases still can be seen in post-elimination era and some kind of leprosy control program is still necessary. Government commitments including adequate financial security and strong policy support are vital. Comprehensive case-finding measures including health promotion, personnel training, reward-offering, with an emphasis on former high or middle endemic areas, are necessary to improve early presentation of suspected cases and to increase suspicion and encourage participation of all relevant medical staff. Symptom surveillance based on a powerful transfer center may play an important role in the early detection of new cases in post-elimination era.

A Review of Measles Outbreak Cost Estimates From the United States in the Postelimination Era (2004-2017): Estimates by Perspective and Cost Type.

Despite the elimination of measles in the United States (US) in the year 2000, cases continue to occur, with measles outbreaks having occurred in various jurisdictions in the US in 2018 and 2019. Understanding the cost associated with measles outbreaks can inform cost-of-illness and cost-effectiveness studies of measles and measles prevention. We performed a literature review and identified 10 published studies from 2001 through 2018 that presented cost estimates from 11 measles outbreaks. The median total cost per measles outbreak was $152 308 (range, $9862-$1 063 936); the median cost per case was $32 805 (range, $7396-$76 154) and the median cost per contact was $223 (range, $81-$746). There were limited data on direct and indirect costs associated with measles. These findings highlight how costly measles outbreaks can be, the value of this information for public health department budgeting, and the importance of more broadly documenting the cost of measles outbreaks.

A Study of Indices in Smear Positive Leprosy in Post-Elimination Era: Experience at a Teaching Tertiary Care Centre

Background: Leprosy is an oldest chronic infectious disease known to mankind that predominantly affects the skin and peripheral nerves. Objective: To evaluate the bacteriological and morphological indices in smear positive cases. Materials and Method: Retrospective observational study was undertaken for one year duration on suspected cases of leprosy. Smears were prepared from one from each of the ear lobes by slit and scrap method and one from the site of lesion. Smears were stained with modified Ziehl-Neelsen stain and bacteriological/morphological indices were calculated. Results: Among 345 clinically suspected cases, 160 (46.38%) were multibacillary with male to female ratio 1.9:1 and most of cases from rural area of lower/middle class of third and fourth decade. All the three sites smears were positive in 112 (70%) cases. 66 (41.25%) cases had bacteriological index of 1+ while more than 1000 bacilli, on average, in 1each oil-immersion field (BI 6+) was observed in 1 (0.62%) cases. In 70 (43.75%) cases morphological index was less than 25 while in 14(8.75%) cases it was more than 50. Conclusion: Bacteriological and morphological index is one of the most important tools for diagnosis, classification, monitoring of treatment and disease severity.