Teledermatology to Improve Access to and Quality of Skin Care in Eastern Indonesia.

Skin diseases are a major public health concern in Indonesia, although access to specialized care in remote areas is limited. We initiated a low-cost teledermatology service in Sumba, a remote island in eastern Indonesia. Eighteen healthcare workers (HCWs) at five primary healthcare centers received training to manage common skin diseases and submit clinical cases beyond their expertise to an online platform. Submitted cases were reviewed by at least one dermatologist. Diagnostic agreement between HCWs and dermatologists was calculated. The HCWs participated in a satisfaction survey 2 years after project initiation. Since October 2020, of 10,384 patients presenting with skin complaints in a 24-month period, 307 (3%) were submitted for a teledermatology consultation. The most frequent skin diseases were infections and infestations (n = 162, 52.8%) and eczematous (85, 27.7%) and inflammatory (17, 5.5%) conditions. Fifty-three patients (17.3%) were diagnosed with a neglected tropical skin disease, including leprosy and scabies. Dermatologist advice was provided within a median of 50 minutes (interquartile range, 18-255 minutes), with 91.9% of consultations occurring within 24 hours. The diagnostic agreement level between HCWs and dermatologists significantly improved over time, from 46.9% in the first 6-month period (κ = 0.45; 95% CI, 0.37-0.54) to 77.2% in the last 6-month period (κ = 0.76; 95% CI, 0.67-0.86; global P < 0.001). The HCWs reported that the teledermatology service was extremely/very useful in supporting daily practice (100%) and improved their knowledge of skin diseases tremendously/a lot (92%). Teledermatology can improve accessibility and quality of skin services in medically underserved areas, providing opportunities for scalability and knowledge transfer to frontline HCWs.

Modified tarsorrhaphy versus gold weight implant technique for paralytic lagophthalmos treatment in patients with leprosy: One-year observation of a randomized controlled trial study.

Trial design: This study was a multicenter, Prospective Randomized Open-label Blinded-Endpoint (PROBE) clinical trial, parallel-group study conducted in Indonesia (three sites). Methods: The aim of this study was to compare the effectivity and efficiency of modified tarsorrhaphy (MT) and gold weight implant (GWI) techniques in the surgical treatment of paralytic lagophthalmos in patients with leprosy. The study sample consisted of 23 eyes, with 11 eyes in the MT group and the remaining 12 eyes in the GWI group-the control group. Results: The central eyelid margin distance (lagophthalmos distance) decreased when gentle pressure was applied in the MT (3.09 mm to 0.43 mm) and GWI groups (3.21 mm to 0.83 mm) at postoperative year 1. The Ocular Surface Disease Index score, the tear break-up time, and the Schirmer test without and with anesthesia in the MT and GWI groups showed a p-value of > 0.05. Epitheliopathy improvement occurred in 54.55% of the MT group and 58.33% of the GWI group. Corneal sensitivity change in the inferior quadrant of the MT group (50.00 to 51.30 mm) and in the GWI group (49.61 to 52.93 mm) resulted in a p > 0.05. Postoperative complications occurred in 15% of patients in the GWI group. In addition, the surgery duration of both techniques was similar. Furthermore, the surgery cost in the MT and GWI groups yielded a p < 0.05. Conclusion: The MT technique is as effective as the GWI technique but more efficient than the GWI technique as a surgical treatment for paralytic lagophthalmos in patients with leprosy. Clinical trial registration: [www.ClinicalTrials.gov], identifier [NCT0494 4498].

COMPARING SOCIO-ECONOMIC CONDITIONS OF MOTHER AND CHILDREN WITH LEPROSY IN ENDEMIC AND NON-ENDEMIC AREAS IN EAST JAVA, INDONESIA.

BACKGROUND: Leprosy is a disease that causes social, psychological, and economic issues. Failure to treat the causes of the immune system dysregulation in endemic areas of leprosy conditions makes the transmission of the bacteria easier. This paper aims to analyze the comparison of family income, occupation types of mothers and fathers, number of children, access to health facilities, and education of mothers, fathers, and children in mothers and children with leprosy in endemic and non-endemic areas. MATERIALS AND METHODS: A cross sectional study by survey was done in both an endemic and a non-endemic area of leprosy in Tuban Regency, East Java, Indonesia. Retrieval of research data was done using interview techniques. Respondents who participated in this study were 106 pairs of mother and child respondents who met the research restriction criteria. Subjects were divided into 5groups based on diagnosis of leprosy and area of living. Bivariate analysis was performed by comparing the independent variables in each group A, B, C, and D with group E. RESULTS: It was found that the variables that differed significantly between the endemic and non-endemic areas were the variable number of children with a p-value=0.004, family income with a p-value=0.049 and the variable mother's education with a p-value=0.016. Meanwhile, other variables do not have significant difference. CONCLUSIONS: We found significant difference on the number of children, father's education, mother's education, and family income. These variables can be a risk factor for leprosy. To make efforts to prevent the transmission of leprosy, stakeholders should consider these factors.

Comparison of IL-17 and FOXP3+ Levels in Maternal and Children Leprosy Patients in Endemic and Nonendemic Areas.

Leprosy, a chronic infection caused by M. leprae, has a complex transmission problem that makes eradication programs difficult. New cases and ongoing transmission of leprosy in endemic areas make individuals living in endemic environments vulnerable to leprosy. This can be caused by the dysregulation of immune system in individuals living in leprosy-endemic areas. Although the number of male leprosy patients is higher, female leprosy patients have more impact on the family health status due to close contact with family members, roles in the household, and parenting. This could cause the increased number of children leprosy patients. We investigated the dysregulation of immune system by comparing IL-17 and FOXP3+ levels occurring in maternal and child leprosy patients in endemic and nonendemic areas. The results of the study found a statistically significant difference in IL-17 levels between the MB leprosy patient group and the control group (p=0.048), where higher levels of IL-17 are observed in the control group. A significant difference also was found in FOXP3+ levels between the group of healthy children living in endemic and those living in nonendemic areas (p=0.047), where higher FOXP3+ is observed in the healthy children living in endemic areas group.

Correlation Analysis between Household Hygiene and Sanitation and Nutritional Status and Female Leprosy in Gresik Regency.

Leprosy, also known as morbus Hansen's disease, is a chronic disease caused by M. leprae. Leprosy attacks various parts of the body including nerves and skin. The most important factor in the occurrence of leprosy is the sources of transmission and contact, both from patients and the environment. Household conditions where the person lives and the nutritional status of the individual can be a risk factor for leprosy. Household hygiene and sanitation can be seen from several aspects, like the physical environment of the house, clean water facilities, personal hygiene, availability of latrines, waste disposal facilities, and garbage disposal. This study was aimed to determine the correlation between household hygiene sanitation and nutritional status with females with leprosy in Gresik Regency. This case-control study was conducted in December 2019 in Gresik Regency. The subjects of this study were 74 respondents taken by consecutive sampling techniques. Retrieval of data was carried out using observations from the healthy house component questionnaire, personal hygiene questionnaire, and direct measurement. Data were analyzed using the chi-square test. The results showed significant correlation between physical environment of the house (p=0.001, OR = 0.104), clean water facilities (p=0.008, OR = 0.261), availability of latrines (p=0.018, OR = 0.209), waste disposal facilities (p=0.015, OR = 0.291), and personal hygiene (p=0.001, OR = 2.850) and female leprosy in Gresik Regency. There is no correlation between nutritional status (p=0.085, OR = 0.422) and wastewater disposal waste (p=0.183, OR = 0.486) and female leprosy in this study.

Association of a missense mutation of the laminin alpha2 gene with tuberculoid type of leprosy in Indonesian patients.

Leprosy, an infection caused by Mycobacterium leprae, has a specific tropism for the myelinating Schwann cells of peripheral nerves. Recently, the G domain of laminin alpha2 has been shown to be a mediator for M. leprae to bind to alpha-dystroglycan in Schwann cells. In order to analyse the association of leprosy with the mediator, three genetic polymorphisms encoding the G domain of the laminin alpha2 chain were analysed by direct sequencing in 53 leprosy patients and 58 healthy contact individuals from Indonesia. There was no significant difference in the incidence of the polymorphisms between patients and non-patients. Remarkably, it was found that a missense mutation (T7809C) substituting valine with alanine (V2587A) was found to be more frequent in the tuberculoid type than in the lepromatous type leprosy. It is supposed that this missense mutation is one of the determinant factors in the early onset of peripheral nerve damage in Indonesian tuberculoid leprosy patients.

Humoral and cellular immune reactivity to recombinant M. leprae antigens in HLA-Typed leprosy patients and healthy controls

In our search for Mycobacterium leprae antigens that might specifically induce immunity or immunopathology, we have tested both humoral and cellular immune reactivity against purified recombinant M. leprae antigens in 29 paucibacillary (PB), 26 multibacillary (MB) leprosy patients, and 47 matched healthy contacts. The following M. leprae antigens were tested: 2L-1 (65L-1, GroEl-1), 2L-2 (65L-2, GroEl-2), 4L (SoDA), 43L, 10L (B) and 25L (Sra). The individuals were also typed for HLAD-RB1 and DQB1 in order to see whether leprosy status and/or immune reactivity to these antigens might be associated with certain HLA types. We also tested sera from another 48 patients before, during and after multidrug therapy (MDT) to study the relationship between antibody reactivity to recombinant M. leprae antigens and MDT. Antibody titers to the four recombinant M. leprae antigens tested and to D-BSA were higher in MB patients compared to PB patients and healthy controls, and declined with treatment. From a diagnostic or monitoring point of view none of the recombinant antigens seemed to be an improvement over D-BSA, mainly due to the lower sensitivity. IgG subclasses were measured in positive sera of untreated patients. These were mainly of the IgG1 and IgG3 subclasses, but subclass diversity was also observed and antigen dependent: all four subclasses could be detected against 10L (B), only IgG1 and IgG3 against 43L and only IgG1 against 25L and 2L-1. Cellular immune reactivity against the purified recombinant M. leprae antigens was measured in a lymphocyte stimulation test (LST). As for M. leprae, there was an inverse correlation between antibody and T-cell reactivity. However, the number of LST responders to recombinant antigens was much lower than to M. leprae. The 43L antigen was recognized most often (19%-24% of individuals tested) and more often than the 10L (B) antigen (10%-12%). No clear correlation was observed with leprosy type or protection and, in general, M. leprae nonresponders were also negative with recombinant antigens. Finally, we confirmed that HLA-DRB1*02 is associated with leprosy in this population, and we observed an association between DQB1*0601 and lepromatous leprosy. The number of positive individuals was too small to allow a meaningful analysis of the relationship between HLA type and immune reactivity. Although these data do not allow a conclusion as to one of these purified recombinant antigens being either protection or disease related, the antigen-dependent IgG subclass diversity warrants further study on antigen-specific qualitative differences in immune reactivity that may be relevant for the outcome of an infection with M. leprae.