Viral co-infections in leprosy: a scoping review.

CONTEXT: The most reported viral co-infections in leprosy are human immunodeficiency virus (HIV), human T-cell lymphotropic virus (HTLV), hepatitis B virus (HBV), hepatitis C virus (HCV), and SARS-CoV-2. In co-infections, the burden of an agent can be increased or decreased by the presence of others. To address this issue, we need to fully understand their prevalence, risk factors, immunology, clinical manifestations, and treatment. The purpose of this scoping review is to describe the clinical and epidemiological characteristics of the most reported viral co-infections in leprosy to inform clinicians and guide future research. METHODS: The authors conducted a literature search of five databases for articles on each of the aforementioned co-infections published prior to October 2022. Two independent reviewers conducted the selection process and identified 53 papers meeting the study inclusion criteria. The data extraction process and evidence synthesis were conducted by one reviewer and double-checked by a second one, consistent with best practice recommendations for scoping reviews. RESULTS: For all assessed viruses, most studies reported prevalence rates in leprosy patients higher than the general population. Studies found that HTLV, HBV, and HCV chronic infections were highest in multibacillary leprosy, whereas HIV was mostly found in paucibacillary leprosy, and SARS-Cov-2 affected leprosy subtypes equally. Overall, co-infections were also associated with higher rates of leprosy reactions, except for COVID-19. Forty-six percent of the studies discussed issues related to treatment, which led to favorable outcomes for the most part. CONCLUSIONS: This review summarizes the existing literature on viral co-infections in leprosy patients, generating valuable insights and recommending areas for future research.

A Structural Competency Curriculum for Primary Care Providers to Address the Opioid Use Disorder, HIV, and Hepatitis C Syndemic.

The interrelated epidemics of opioid use disorder (OUD) and HIV and hepatitis C virus (HCV) infection have been identified as one of the most pressing syndemics facing the United States today. Research studies and interventions have begun to address the structural factors that promote the inter-relations between these conditions and a number of training programs to improve structural awareness have targeted physician trainees (e.g., residents and medical students). However, a significant limitation in these programs is the failure to include practicing primary care providers (PCPs). Over the past 5 years, there have been increasing calls for PCPs to develop structural competency as a way to provide a more integrated and patient-centered approach to prevention and care in the syndemic. This paper applies Metzel and Hansen's (1) framework for improved structural competency to describe an educational curriculum that can be delivered to practicing PCPs. Skill 1 involves reviewing the historical precedents (particularly stigma) that created the siloed systems of care for OUD, HIV, and HCV and examines how recent biomedical advances allow for greater care integration. To help clinicians develop a more multidisciplinary understanding of structure (Skill 2), trainees will discuss ways to assess structural vulnerability. Next, providers will review case studies to better understand how structural foundations are usually seen as cultural representations (Skill 3). Developing structural interventions (Skill 4) involves identifying ways to create a more integrated system of care that can overcome clinical inertia. Finally, the training will emphasize cultural humility (Skill 5) through empathetic and non-judgmental patient interactions. Demonstrating understanding of the structural barriers that patients face is expected to enhance patient trust and increase retention in care. The immediate objective is to pilot test the feasibility of the curriculum in a small sample of primary care sites and develop metrics for future evaluation. While the short-term goal is to test the model among practicing PCPs, the long-term goal is to implement the training practice-wide to ensure structural competence throughout the clinical setting.

Prevalence of hepatitis B and C virus infection among leprosy patients in a leprosy-endemic region of central Brazil.

Leprosy and hepatitis B virus (HBV) are highly endemic in some regions of the state of Mato Grosso, in central Brazil. The association of leprosy with HBV and hepatitis C virus (HCV) was assessed using a seroprevalence study and 191 leprosy outpatients were included. Demographic data and the clinical classification of leprosy were recorded. Evidence of previous HBV infection was present in 53 patients (27.7%, 95% confidence interval: 21.9-34.5) and two (1%) were HBsAg positive. Five (2.6%) had antibodies to HCV. The prevalence of previous exposure to HBV was higher than expected for an adult population in central Brazil. In contrast, the prevalence of anti-HCV antibodies was not much higher regarding the age range of participants. HBV markers were associated with a higher number of sex partners and the use of injections without proper sterilisation of the syringes. The number of HBV carriers was small, suggesting that there was no increased likelihood of chronification among these patients.

Molecular epidemiology of a hepatitis C virus outbreak in a leprosy sanatorium in Japan.

The hepatitis C virus (HCV) outbreak that occurred between 1940 and 1999 in a closed leprosy sanatorium located on a small island in Japan was analyzed. The analysis of 318 nucleotides in the NS5B region of HCV allowed us to establish the existence of at least three different HCV strains in this sanatorium.

Hepatitis C virus infection in a Japanese leprosy sanatorium for the past 67 years.

Oku-Komyo-En is one of the national leprosy sanatoria, located on a small island in Setouchi city, Okayama prefecture of Japan since 1938. Since autopsies were carried out routinely on almost all patients who had died in the sanatorium up to 1980, approximately 1,000 formalin-fixed autopsy tissue samples were available for analysis. When these samples were reviewed, the pathological data indicated a sharp rise in the death rate caused by cirrhosis of the liver and hepatocellular carcinoma (HCC) since 1960 and 1970, respectively. Hepatitis C virus (HCV) infection is a common cause of HCC in Japan. The presence of HCV RNA was demonstrated in paraffin sections prepared from the autopsied liver tissue fixed in formalin for a prolonged period of time, by employing nested RT-PCR using type-specific primers. The data showed that HCV RNA was detectable in samples of the liver archived as early as 1940, representing the liver tissues kept in formalin for up to 67 years. HCV genotypes 1b and 2a were found by RT-PCR at 85.7% and 14.3%, respectively, in patients with leprosy.

Noble goals, unforeseen consequences: control of tropical diseases in colonial Central Africa and the iatrogenic transmission of blood-borne viruses.

BACKGROUND: In southern Cameroon, 40-50% of individuals born before 1945 have antibodies against hepatitis C virus (HCV), suggesting massive iatrogenic transmission of at least one blood-borne virus in the region of the world where SIV(cpz) emerged into HIV-1. OBJECTIVE: To estimate the potential role of disease control programs that used intravenous (IV) drugs in the transmission of blood-borne viruses, especially HCV. Methods We reviewed, for 1921-1959, records of health services in Cameroun, Oubangui-Chari, Gabon and Moyen-Congo. We calculated the incidence of diseases whose treatment required the administration of IV drugs, and compared these with previously published data on HCV prevalence. RESULTS: Several IV drugs were used against African trypanosomiasis, leprosy, yaws and syphilis. However, yaws was the only disease whose incidence was high enough so that up to half of some birth cohorts could have acquired HCV. Yaws incidence varied dramatically between regions, and was often >200 per 1000 per year in southern Cameroon, where extremely high HCV prevalence was found. Yaws incidence peaked between 1935 and 1955, a period which coincided with the emergence of HCV and HIV. CONCLUSION: Age, geographical and temporal distributions of yaws suggest that the HCV epidemic in Cameroon was driven by campaigns against yaws (and, secondarily, syphilis) using arsenicals and other metallic drugs. The same interventions may have exponentially amplified other blood-borne viruses, including SIV(cpz)/HIV-1.

Leprosy and confinement due to leprosy show high association with hepatitis C in Southern Brazil.

Leprosy is a disease, which is accompanied by cellular immunity defects, which may increase the susceptibility of patients in developing co-infections. The association of leprosy with hepatitis C virus (HCV) infection, human immunodeficiency virus types 1 and 2 (HIV 1+2) infection and human T-lymphotropic virus types I and II (HTLV I+II) infection have previously been described in different populations. In this study, the prevalence of these infections was determined in 199 Southern Brazilian leprosy patients and in 681 matched controls. Antibodies to HCV were positive in 3.52% of the patients (7/199) and in 0.15% of the controls (1/681; odds ratio (OR)=24.79; 95% CI=3.03-202.74; p=0.0002). An increased risk of HCV infection was observed in institutionalized patients (OR=14.95; 95% CI=1.76-127.03; p=0.004) and in the lepromatous form of the disease (OR=7.67; 95% CI=0.43-136.62; p=ns). Anti-HIV 1+2 antibodies were positive in only one out-patient (1/199; 0.50%) and in none of the controls (0/681; OR=3.43; 95% CI=0.21-55.16; p>0.05). No leprosy patient was positive for anti-HTLV I+II antibodies. These results demonstrate an increased prevalence of HCV infection in leprosy patients from South Brazil and that both institutionalization and lepromatous form of the disease confer higher risk to HCV infection. These data emphasizes the importance of monitoring hepatitis C and leprosy interactions and the need of special care to institutionalized and lepromatous patients in preventing HCV co-infection.

"They treated me like a leper". Stigmatization and the quality of life of patients with hepatitis C.

OBJECTIVE: Hepatitis C virus is the most prevalent chronic blood-borne infection in the United States, typically acquired through contaminated blood products or needle sharing. We hypothesized that patients with chronic hepatitis C infection experience stigmatization independent of mode of acquisition and that it negatively affects quality of life. DESIGN: Cross-sectional observation study. SETTING: Specialty clinic in a tertiary referral hospital. PATIENTS: Two hundred and ninety outpatients diagnosed with chronic hepatitis C infection and seen in a hepatology clinic. Thirty participants were excluded because of missing data. MEASUREMENTS AND MAIN RESULTS: Patients were asked to complete a demographic profile, a semistructured interview, the Sickness Impact Profile, and the Hospital Anxiety Depression Scale. A team of two blinded coders analyzed the interviews. A total of 147 of the 257 study patients experienced stigmatization that they attributed to the disease. Women were more likely to report perceived stigmatization than men (P <.05). Age, education, professional status, and mode of infection did not influence the likelihood of stigmatization. Stigmatization was associated with higher anxiety (P <.01) and depression (P <.01), worsened quality of life (P <.01), loss of control (P <.01), and difficulty coping (P <.01). Individuals who experienced stigmatization also mentioned problems in their health care (P <.01) and work environment (P <.01) as well as with family members (P <.01). CONCLUSION: Stigmatization is a very common emotionally burdensome experience for patients with hepatitis C, which can erode social support. As it penetrates even into the health care environment, physicians and other care providers should be aware of the existence and impact of such negative stereotyping.

Short report: association between leprosy and hepatitis C infection: a survey in a region of central Brazil.

Prevalence of antibodies to hepatitis C virus (HCV) was determined in 216 Brazilian lepromatous patients (83 outpatients and 133 institutionalized). The overall prevalence was 1.8% after confirmatory tests. No difference in the HCV infection was found between outpatients and institutionalized ones. Our results from this region of Central Brazil are lower than those found in leprosy patients in Africa and in Japan.

Hepatitis C virus antibody, viral RNA and genotypes in leprous patients in Japan.

BACKGROUND/METHODS: Markers of hepatitis C virus infection were tested for in 229 patients with leprosy (male 154, female 75) in Japan. RESULTS: Antibody to hepatitis C virus by a second-generation enzyme immunoassay was detected in 68 patients (30%), and RNA of hepatitis C virus in 41 (18%), in prevalence rates much higher (p < 0.001) than those in matched controls (11/923 or 1.2% and 9/923 or 1.0%, respectively). Hepatitis C virus genotypes were II/1b in 37 (90%), III/2a in three (7%) and IV/2b in one (2%), in which II/1b was more frequently (p < 0.003) represented than in hepatitis C virus carriers without leprosy in Japan (520/767 or 68%). The 41 patients with hepatitis C virus viremia had serum transaminase levels significantly higher than those in the other 188 patients without viremia (p < 0.01). CONCLUSIONS: These results indicate that leprous patients confined in institutions are at high risk of hepatitis C virus infection, and that patients infected with hepatitis C virus should be monitored for liver function and placed on interferon therapy whenever required.

Prevalence of anti-HCV antibodies in western India.

Nearly 2000 serum samples collected from different risk groups from Pune and Bombay metropolitan areas were tested for antibodies to hepatitis C virus (anti-HCV) by Recombinant Immunoblot Assay-3 (RIBA-3). Patients undergoing haemodialysis showed 24.5 per cent seropositivity whereas 5.7 and 5.3 per cent of multiply transfused patients (>2 units) and chronic liver disease patients respectively were anti-HCV positive. Leprosy patients had almost 0.7 per cent seropositivity. In other risk groups the positivity rate was nil. In normal population only one out of 830 persons had anti-HCV antibodies. It is therefore apparent that the prevalence of hepatitis C virus (HCV) in western India is not high. However, special care needs to be taken for dialysis patients. As none of the 430 pregnant women and 86 children below the age of 5 yr were anti-HCV positive, vertical mode of HCV transmission seems to be negligible.

Prevalence of antibodies to hepatitis C virus among patients with leprosy in several African countries and the Yemen.

The prevalence of anti-HCV was determined in 1,309 leprosy patients and a control group of 1,469 subjects from 6 sub-Saharan African countries and the Yemen. Sera found positive by an initial second generation ELISA were subjected to 3 additional confirmatory tests. The anti-HCV prevalence in leprosy patients (7.1%) was significantly higher than in the control group (2.6%). HCV seroprevalence increased with age in both the control and leprosy groups. No statistically significant difference could be found between anti-HCV prevalence and the several clinical forms of leprosy among patients. The results of this study indicate a high degree of exposure or chronic carriage of hepatitis C among leprosy patients.

A survey of antibodies to hepatitis C virus in Ethiopia.

Antibodies to hepatitis C virus (HCV) were measured in 1,580 Ethiopian subjects representing urban and rural populations. Sera found positive by a repeated second generation enzyme immunoassay (EIA) were subjected to three additional confirmatory tests. The overall confirmed seroprevalence was 2.0%. Less than 1% were confirmed to be seropositive in rural communities, with 1.4% positive among blood donors, 1.6% positive among patients with dermatologic disorders, 3.6% among leprosy patients, and 6.0% among patients attending a University Hospital clinic for neurologic disorders. The patients in the groups with leprosy and neurologic disorders have most likely been in ill health for many years and have sought relief by traditional healers or treatment at poorly equipped clinics. This group of patients demonstrated a high prevalence of antibodies to HCV. In Ethiopia, especially in small clinics, there is a shortage of syringes and needles and they have to be reused many times often with inadequate sterilization. Therefore, these syringes and needles may be contaminated, thus being a risk factor for HCV and HIV infection.

[Survey of the antibody to HCV in National Leprosarium Suruga].

Blood specimens from 210 leprosy patients (average age 67.4 years old) and 84 staff members (average age 43.5 years old) in National Leprosarium Suruga were tested for anti-HCV antibody using Ortho's Ab ELISA system. Among the patients, 17 patients had chronic hepatic dysfunction as well as leprosy. Twenty of the 210 patients (9.5%) had anti-HCV antibody in their blood. Eleven of the 17 patients (65%) with chronic hepatic dysfunction were positive for anti-HCV antibody. Only one of the staff member was anti-HCV antibody positive. This high positive ratio of anti-HCV antibody in the leprosy patients is similar to the results of another research reported from National Leprosarium Oku Komyo-En. We, therefore, conclude that the prevalence of anti-HCV antibody in leprosy patients is higher than that of the general population and that anti-HCV antibody is related closely to chronic hepatic dysfunction. Some investigators have recently reported that there was an increased incidence of hepatocellular carcinoma in leprosy patients. And so, it is speculated that this is due to the high prevalence of the hepatitis C virus. However, the reason for this high prevalence of anti-HCV antibody in the sample is obscure.