Efficacy of chemoprophylaxis and immunoprophylaxis in leprosy prevention: a systematic review and network meta-analysis of randomized controlled trials.

BACKGROUND: Vaccination and single-dose rifampin are the main proven effective intervention types for preventing leprosy among contacts of Mycobacterium leprae endemic areas. Currently, no high-quality evidence is available regarding the best prophylactic intervention. OBJECTIVES: Our primary study aim is to detect the most effective prophylactic intervention for the prevention of leprosy. METHODS: In May 2019, 12 databases were searched systematically. Updated search terms were developed in March 2020 to complete an updated search. All randomized controlled trials (RCTs) comparing the different types of chemoprophylactic and immunoprophylactic interventions in leprosy prevention were included. Our participants were contacts of patients with leprosy or people residing in leprosy endemic communities. We searched for different types of chemoprophylactic and immunoprophylactic interventions used in leprosy prevention. We used network meta-analysis and meta-analysis. Quality assessment was performed using Cochrane Risk of Bias for included RCTs, in which all included RCTs were rated to be low to moderate risk. We registered our protocol in Prospero with ID CRD42019143207. RESULTS: Among 11 included studies (326 264 patients) from original and updated search terms, eight were eligible for network meta-analysis (NMA) while four were eligible for MA. Findings suggest that Bacillus Calmette-Guérin (BCG) vaccination was the most effective intervention compared to placebo (risk ratios (RRs) 0.49 (0.30, 0.80), p 0.77), followed by combined BCG vaccination and single-dose rifampicin (SDR) with similarly low values (RR 48%, p 0.77). BCG revaccination was the least effective intervention compared to placebo (RR 1.08 (0.36, 3.22), p 0.26). CONCLUSION: Compared to placebo, the BCG vaccine was the most effective prophylactic intervention. The combination of BCG vaccination + SDR had nearly the same efficacy as BCG vaccination alone, while BCG revaccination was the least effective. Thus, vaccination proved to be a more effective treatment than SDR alone. A well-designed multicenter RCT is warranted to evaluate the safety of these vaccines.

Addressing the drug-resistant tuberculosis challenge through implementing a mixed model of care in Uganda.

Worldwide, Drug-resistant Tuberculosis (DR-TB) remains a big problem; the diagnostic capacity has superseded the clinical management capacity thereby causing ethical challenges. In Sub-Saharan Africa, treatment is either inadequate or lacking and some diagnosed patients are on treatment waiting lists. In Uganda, various health system challenges impeded scale-up of DR-TB care in 2012; only three treatment initiation facilities existed, with only 41 of the estimated 1010 RR-TB/MDR-TB cases enrolled on treatment yet 300 were on the waiting list and there was no DR-TB treatment scale-up plan. To scale up care, the National TB and leprosy Program (NTLP) with partners rolled out a DR-TB mixed model of care. In this paper, we share achievements and outcomes resulting from the implementation of this mixed Model of DR-TB care. Routine NTLP DR-TB program data on treatment initiation site, number of patients enrolled, their demographic characteristics, patient category, disease classification (based on disease site and human immunodeficiency virus (HIV) status), on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART) statuses, culture results, smear results and treatment outcomes (6, 12, and 24 months) from 2012 to 2017 RR-TB/MDR-TB cohorts were collected from all the 15 DR-TB treatment initiation sites and descriptive analysis was done using STATA version 14.2. We presented outcomes as the number of patient backlog cleared, DR-TB initiation sites, RR-TB/DR-TB cumulative patients enrolled, percentage of co-infected patients on the six, twelve interim and 24 months treatment outcomes as per the Uganda NTLP 2016 Programmatic Management of drug-resistant Tuberculosis (PMDT) guidelines (NTLP, 2016). Over the period 2013-2015, the RR-TB/MDR-TB Treatment success rate (TSR) was sustained between 70.1% and 74.1%, a performance that is well above the global TSR average rate of 50%. Additionally, the cure rate increased from 48.8% to 66.8% (P = 0.03). The Uganda DR-TB mixed model of care coupled with early application of continuous improvement approaches, enhanced cohort reviews and use of multi-disciplinary teams allowed for rapid DR-TB program expansion, rapid clearance of patient backlog, attainment of high cumulative enrollment and high treatment success rates. Sustainability of these achievements is needed to further reduce the DR-TB burden in the country. We highly recommend this mixed model of care in settings with similar challenges.

Leprosy post-exposure prophylaxis in the Indian health system: A cost-effectiveness analysis.

India has the highest burden of leprosy in the world. Following a recent WHO guideline, the Indian National Leprosy Programme is introducing post-exposure prophylaxis with single-dose rifampicin (SDR-PEP) in all high-endemic districts of the country. The aim of this study is to estimate the long-term cost-effectiveness of SDR-PEP in different leprosy disability burden situations. We used a stochastic individual-based model (SIMCOLEP) to simulate the leprosy new case detection rate trend and the impact of implementing contact screening and SDR-PEP from 2016 to 2040 (25 years) in the Union Territory of Dadra Nagar Haveli (DNH) in India. Effects of the intervention were expressed as disability adjusted life years (DALY) averted under three assumption of disability prevention: 1) all grade 1 disability (G1D) cases prevented; 2) G1D cases prevented in PB cases only; 3) no disability prevented. Costs were US$ 2.9 per contact. Costs and effects were discounted at 3%. The incremental cost per DALY averted by SDR-PEP was US$ 210, US$ 447, and US$ 5,673 in the 25th year under assumption 1, 2, and 3, respectively. If prevention of G1D was assumed, the probability of cost-effectiveness was 1.0 at the threshold of US$ 2,000, which is equivalent to the GDP per capita of India. The probability of cost-effectiveness was 0.6, if no disability prevention was assumed. The cost per new leprosy case averted was US$ 2,873. Contact listing, screening and the provision of SDR-PEP is a cost-effective strategy in leprosy control in both the short (5 years) and long term (25 years). The cost-effectiveness depends on the extent to which disability can be prevented. As the intervention becomes increasingly cost-effective in the long term, we recommend a long-term commitment for its implementation.

[Acceptability of chemoprophylaxis in an endemic area for leprosy: the PEP-Hans Brazil Project]. / Aceitabilidade da quimioprofilaxia em área endêmica para a hanseníase: projeto PEP-Hans Brasil.

The aim was to analyze the acceptability of chemoprophylaxis with single-dose rifampicin (PEP) in contacts, index leprosy cases, and health professionals and related factors that can influence adherence. A qualitative content analysis study was performed after application of semi-structured interviews according to the protocol proposed in the LPEP program (2016) drafted at Alta Floresta, Mato Grosso State, Brazil, in July 2016. Study participants included individuals with leprosy, contacts, and health professionals. The QRS NVivo software version 10 was used. A total of 80 individuals were contacted, including 54 (67%) contacts, 11 (14%) index cases, and 15 (19%) health professionals. 94% of the contacts (51/54) took PEP. Three PEP categories were identified: understanding, acceptance, and expectation towards the intervention. Understanding proved to be related to care by the health team. Acceptance (or lack thereof) of the medication was related to fear, trust, and protection, the strategy's operability, self-esteem, and insecurity regarding the intervention. Expectation towards the intervention was related to wellbeing, prevention of the disease, sequelae, decrease in public expenditures, and expanded access. Participants acknowledged the relevance of the PEP strategy based on the possibility of interrupting the transmission chain, reduction in new cases, and improved quality of life. Insecurity in taking the medication and the possibility of the disease manifesting itself had a negative influence on acceptance of PEP, while prior information on the PEP strategy helped strengthen trust in the health professionals and the medication's acceptance.

O objetivo deste artigo foi analisar a aceitabilidade da quimioprofilaxia com rifampicina em dose única (PEP) entre os contatos, casos índices de hanseníase e profissionais da saúde e fatores relacionados que possam influenciar na adesão. Realizou-se um estudo qualitativo de análise de conteúdo após aplicação de entrevistas semiestruturadas segundo protocolo proposto no programa LPEP (2016), realizado em Alta Floresta, Mato Grosso, Brasil, em julho de 2016. Participaram do estudo indivíduos notificados com hanseníase, contatos e profissionais da saúde. Utilizou-se o software QRS NVivo versão 10. Foram contatados 80 indivíduos, sendo 54 (67%) contatos, 11 (14%) casos índices e 15 (19%) profissionais de saúde. Dentre os contatos, 94% (51/54) tomaram PEP. Foram identificadas 3 categorias quanto à PEP: compreensão, aceitação e expectativa da intervenção. A compreensão se mostrou relacionada ao cuidado da equipe de saúde. Aceitar ou não a medicação revelou-se relacionada ao medo, confiança e proteção, operacionalidade da estratégia, autoestima e insegurança quanto à intervenção. A expectativa da intervenção relacionou-se ao bem-estar, prevenção da doença e de sequelas, diminuição de gastos públicos e ampliação do acesso. Houve reconhecimento da relevância da estratégia PEP pela possibilidade de interrupção da cadeia de transmissão, diminuição de casos novos e melhora na qualidade de vida. A insegurança em tomar a medicação e de a doença se manifestar influenciaram negativamente à aceitação da PEP; por outro lado, as informações prévias sobre a estratégia PEP contribuíram para o fortalecimento da confiança nos profissionais de saúde e para a aceitabilidade da medicação.

El objetivo fue analizar la aceptabilidad de la quimioprofilaxis con rifampicina en dosis única (PEP) entre los contactos, casos índices de hanseniasis y profesionales de salud, así como los factores relacionados que puedan influenciar en la adhesión al tratamiento. Se realizó un estudio cualitativo de análisis de contenido, tras la realización de entrevistas semiestructuradas, según el protocolo propuesto en el programa LPEP (2016), realizado en Alta Floresta, Mato Grosso, Brasil, en julio de 2016. Participaron en el estudio individuos diagnosticados con hanseniasis, contactos y profesionales de la salud. Se utilizó el software QRS NVivo versión 10. Se contactó con 80 individuos, siendo 54 (67%) contactos, 11 (14%) casos índices y 15 (19%) profesionales de salud. Entre los contactos 94% (51/54) tomaron PEP. Se identificaron 3 categorías respecto a la PEP: comprensión, aceptación y expectativa de intervención. La comprensión estuvo relacionada con el cuidado del equipo de salud. El aceptar o no la medicación estuvo relacionado con el miedo, confianza y protección, operatividad de la estrategia, autoestima e inseguridad de la intervención. La expectativa de la intervención estuvo relacionada con el bienestar, prevención de la enfermedad, así como secuelas, disminución de gasto público y ampliación del acceso. Existió un reconocimiento de la relevancia de la estrategia PEP por la posibilidad de interrupción de la cadena de transmisión, disminución de casos nuevos y mejora en la calidad de vida. La inseguridad en tomar la medicación y de que la enfermedad se manifestara influenciaron negativamente en la aceptación de la PEP, por otro lado, la información previa sobre la estrategia PEP contribuyó al fortalecimiento de la confianza en los profesionales de salud y a la aceptabilidad de la medicación.

Aceitabilidade da quimioprofilaxia em área endêmica para a hanseníase: projeto PEP-Hans Brasil / Acceptability of chemoprophylaxis in an endemic area for leprosy: the PEP-Hans Brazil Project / Aceptabilidad de la quimioprofilaxis en un área endémica de hanseniasis: Proyecto PEP-Hans Brasil

Resumo: O objetivo deste artigo foi analisar a aceitabilidade da quimioprofilaxia com rifampicina em dose única (PEP) entre os contatos, casos índices de hanseníase e profissionais da saúde e fatores relacionados que possam influenciar na adesão. Realizou-se um estudo qualitativo de análise de conteúdo após aplicação de entrevistas semiestruturadas segundo protocolo proposto no programa LPEP (2016), realizado em Alta Floresta, Mato Grosso, Brasil, em julho de 2016. Participaram do estudo indivíduos notificados com hanseníase, contatos e profissionais da saúde. Utilizou-se o software QRS NVivo versão 10. Foram contatados 80 indivíduos, sendo 54 (67%) contatos, 11 (14%) casos índices e 15 (19%) profissionais de saúde. Dentre os contatos, 94% (51/54) tomaram PEP. Foram identificadas 3 categorias quanto à PEP: compreensão, aceitação e expectativa da intervenção. A compreensão se mostrou relacionada ao cuidado da equipe de saúde. Aceitar ou não a medicação revelou-se relacionada ao medo, confiança e proteção, operacionalidade da estratégia, autoestima e insegurança quanto à intervenção. A expectativa da intervenção relacionou-se ao bem-estar, prevenção da doença e de sequelas, diminuição de gastos públicos e ampliação do acesso. Houve reconhecimento da relevância da estratégia PEP pela possibilidade de interrupção da cadeia de transmissão, diminuição de casos novos e melhora na qualidade de vida. A insegurança em tomar a medicação e de a doença se manifestar influenciaram negativamente à aceitação da PEP; por outro lado, as informações prévias sobre a estratégia PEP contribuíram para o fortalecimento da confiança nos profissionais de saúde e para a aceitabilidade da medicação(AU).

Abstract: The aim was to analyze the acceptability of chemoprophylaxis with single-dose rifampicin (PEP) in contacts, index leprosy cases, and health professionals and related factors that can influence adherence. A qualitative content analysis study was performed after application of semi-structured interviews according to the protocol proposed in the LPEP program (2016) drafted at Alta Floresta, Mato Grosso State, Brazil, in July 2016. Study participants included individuals with leprosy, contacts, and health professionals. The QRS NVivo software version 10 was used. A total of 80 individuals were contacted, including 54 (67%) contacts, 11 (14%) index cases, and 15 (19%) health professionals. 94% of the contacts (51/54) took PEP. Three PEP categories were identified: understanding, acceptance, and expectation towards the intervention. Understanding proved to be related to care by the health team. Acceptance (or lack thereof) of the medication was related to fear, trust, and protection, the strategy's operability, self-esteem, and insecurity regarding the intervention. Expectation towards the intervention was related to wellbeing, prevention of the disease, sequelae, decrease in public expenditures, and expanded access. Participants acknowledged the relevance of the PEP strategy based on the possibility of interrupting the transmission chain, reduction in new cases, and improved quality of life. Insecurity in taking the medication and the possibility of the disease manifesting itself had a negative influence on acceptance of PEP, while prior information on the PEP strategy helped strengthen trust in the health professionals and the medication's acceptance(AU).

Resumen: El objetivo fue analizar la aceptabilidad de la quimioprofilaxis con rifampicina en dosis única (PEP) entre los contactos, casos índices de hanseniasis y profesionales de salud, así como los factores relacionados que puedan influenciar en la adhesión al tratamiento. Se realizó un estudio cualitativo de análisis de contenido, tras la realización de entrevistas semiestructuradas, según el protocolo propuesto en el programa LPEP (2016), realizado en Alta Floresta, Mato Grosso, Brasil, en julio de 2016. Participaron en el estudio individuos diagnosticados con hanseniasis, contactos y profesionales de la salud. Se utilizó el software QRS NVivo versión 10. Se contactó con 80 individuos, siendo 54 (67%) contactos, 11 (14%) casos índices y 15 (19%) profesionales de salud. Entre los contactos 94% (51/54) tomaron PEP. Se identificaron 3 categorías respecto a la PEP: comprensión, aceptación y expectativa de intervención. La comprensión estuvo relacionada con el cuidado del equipo de salud. El aceptar o no la medicación estuvo relacionado con el miedo, confianza y protección, operatividad de la estrategia, autoestima e inseguridad de la intervención. La expectativa de la intervención estuvo relacionada con el bienestar, prevención de la enfermedad, así como secuelas, disminución de gasto público y ampliación del acceso. Existió un reconocimiento de la relevancia de la estrategia PEP por la posibilidad de interrupción de la cadena de transmisión, disminución de casos nuevos y mejora en la calidad de vida. La inseguridad en tomar la medicación y de que la enfermedad se manifestara influenciaron negativamente en la aceptación de la PEP, por otro lado, la información previa sobre la estrategia PEP contribuyó al fortalecimiento de la confianza en los profesionales de salud y a la aceptabilidad de la medicación(AU).

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

BACKGROUND: The 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. METHODOLOGY: The 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 FINDINGS: Our 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. CONCLUSIONS: The 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.

Trend analysis of leprosy in Morocco between 2000 and 2017: Evidence on the single dose rifampicin chemoprophylaxis.

BACKGROUND: Morocco has achieved the goal of leprosy elimination as a public health problem several years ago (less than 1 case/ 10 000 habitant). The aim of this study was to analyze trends of leprosy detection during the last 17 years taking into consideration the implementation of single dose rifampicin chemoprophylaxis (SDRC) started in 2012. METHODOLOGY: Time series of leprosy cases detected at national level between 2000 and 2017. Variable collected for each year were leprosy per 100000 H, age category, gender, origin, regions, grade of disabilities and clinical forms. The detection time series was assessed by Joinpoint Regression Analysis. Annual percentage changes (APCs) were estimated to identify the years (joinpoint) when significant changes occurred in the trend. We therefore examined trends in leprosy detection according to epidemiological variables. FINDINGS: Joinpoint regression showed a reduction in the detection rate between 2000 and 2017. The APC for the period 2012-2017 (-16.83, 95% CI: -29.2 to -2.3, p <0.05) was more pronounced than that of the previous period 2000-2012 (- 4.68, 95% CI: -7.3 to -2.0, p <0.05); with a significant break in the same joinpoint year SDRC implementation. In stratified analysis, case detection decreased, but not significantly, after the joinpoint years in men, children, multi-bacillary cases, grade 0-1 disabilities, rural and urban cases and in ten regions. CONCLUSIONS: Leprosy detection was declining over years with a significant reduction by 16% per year from 2012 to 2017. SDRC may reduce leprosy detection over the years following its administration.

Trends and patterns in leprosy in nine states of the Republic of the Sudan 7 years after the introduction of routine contact screening.

Background: This paper analyzes the trends of key indicators reflecting the epidemiological situation of leprosy in nine different states of the Republic of the Sudan after the introduction of a systematic contact screening in 2010. Methods: The routinely assessed data from the leprosy control program from 2010 to 2016 were analyzed. Results: Despite, intense contact screening, the overall number of new cases detected showed a decreasing trend. The female:male ratio among new cases was constantly low. The overall average number of contacts needed to screen in order to detect a new case among contacts was 64. However, this number varied significantly in the nine states under investigation, with the best yield being observed in the state with the lowest case detection rate. Conclusions: The total number of new cases of leprosy in nine states of the Republic of the Sudan has shown declining tendencies since 2010. Our data are not suggestive of a significant impact of contact screening on the trends of leprosy key indicators. Overall, contact screening proved to be efficient in most states, including those that exhibited very low annual new case detection rates (ANCDRs). Sensitization of personnel undergoing training and measures improving access of females to leprosy services are urgently needed.

Effectiveness of rifampicin chemoprophylaxis in preventing leprosy in patient contacts: a systematic review of quantitative and qualitative evidence.

BACKGROUND: Individuals in contact with patients who have leprosy have an increased risk of disease exposure, which reinforces the need for chemoprophylactic measures, such as the use of rifampicin. OBJECTIVES: The objective of the review was to synthesize the best available evidence regarding the effectiveness of rifampicin chemoprophylaxis for contacts with patients with leprosy, and to synthesize the best available evidence on the experience and acceptability of rifampicin chemoprophylaxis as reported by the contacts and health professionals involved in the treatment of leprosy or Hansen's disease. INCLUSION CRITERIA TYPES OF PARTICIPANTS: In the quantitative component, individuals in contact with leprosy patients were included. In the qualitative component, in addition to contacts, health professionals who were in the practice of treating leprosy were included. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: The quantitative component considered as an intervention rifampicin at any dose, frequency and mode of administration, and rifampicin combination regimens.The qualitative component considered as phenomena of interest the experience and acceptability of rifampicin chemoprophylaxis. TYPES OF STUDIES: The quantitative component considered experimental and observational studies whereas the qualitative component considered studies that focused on qualitative data, including but not limited to, designs such as phenomenology, grounded theory, ethnography and action-research. OUTCOMES: The quantitative component considered studies that reported on outcomes such as the development of clinical leprosy in the contacts of patients who had leprosy, incidence rates, adverse effects and safety/harmful effects of the intervention. SEARCH STRATEGY: A three-step strategy for published and unpublished literature was used. The search for published studies included: PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Scopus, Web of Science, National Institute for Health and Clinical Excellence, Latin American and Caribbean Health Sciences Literature; and Google Scholar and EVIPnet for unpublished studies. Studies published from the time of the respective database inception to January 2016 in English, Spanish, Portuguese, Japanese and Chinese were considered. METHODOLOGICAL QUALITY: Two reviewers independently assessed the studies for methodological quality using standardized critical appraisal instruments from the Joanna Briggs Institute. DATA EXTRACTION: Standardized data extraction tools developed by the Joanna Briggs Institute were used to extract quantitative and qualitative data from papers included in the review. DATA SYNTHESIS: Due to clinical and methodological heterogeneity in the interventions of the included studies, no statistical meta-analysis was possible. Quantitative and qualitative research findings are presented in narrative form. RESULTS: Following critical appraisal, eight studies were included in this review, seven quantitative and one qualitative. The reduction in incidence of leprosy, using one dose of rifampicin in the first two years, was 56.5%; in the follow up period of one to four years, the reduction was 34.9%. The combination of rifampicin and the Bacillus Calmette-Guérin vaccine showed a preventative effect of 80% against the disease. The only controlled clinical trial using two doses of rifampicin was community-based and did not indicate effectiveness of the intervention. The qualitative findings showed social acceptability of rifampicin. CONCLUSIONS: Chemoprophylaxis with one dose of rifampicin is found to be effective in preventing contacts of leprosy patients from contracting the disease. Also, there is indication that this strategy is socially accepted.

Innovative tools and approaches to end the transmission of Mycobacterium leprae.

Leprosy control has seen little innovation and only limited progress in the past decade. However, research on the disease has increased and important innovations are underway. Here, we comment on efforts to develop tools and approaches to detect leprosy and to stop the transmission of Mycobacterium leprae, the causative bacillus of the disease. The tracing and screening of contacts of known patients with leprosy promises to strengthen early diagnosis, while preventive chemotherapy will reduce the risk of contacts developing the disease by 50-60% within 2 years of administration. Until now, diagnosis has been mainly based on the presence of signs and symptoms, but efforts are underway to develop inexpensive, reliable, point-of-care tests to diagnose infection. Development of a leprosy-specific vaccine that boosts long-lasting T-cell responses is also a research objective. As for launching a programme to interrupt transmission, two interlinked tools-epidemiological modelling and the concept of an investment case-are being developed to explore the feasibility and costs of such a programme and its overall effect on individuals and society. We believe that sustained innovation is needed and that only a combination of tools and approaches holds promise to end M leprae transmission.

Leprosy New Case Detection Trends and the Future Effect of Preventive Interventions in Pará State, Brazil: A Modelling Study.

BACKGROUND: Leprosy remains a public health problem in Brazil. Although the overall number of new cases is declining, there are still areas with a high disease burden, such as Pará State in the north of the country. We aim to predict future trends in new case detection rate (NCDR) and explore the potential impact of contact tracing and chemoprophylaxis on NCDR in Pará State. METHODS: We used SIMCOLEP, an existing individual-based model for the transmission and control of M. leprae, in a population structured by households. The model was quantified to simulate the population and observed NCDR of leprosy in Pará State for the period 1990 to 2014. The baseline scenario was the current control program, consisting of multidrug therapy, passive case detection, and active case detection from 2003 onwards. Future projections of the NCDR were made until 2050 given the continuation of the current control program (i.e. baseline). We further investigated the potential impact of two scenarios for future control of leprosy: 1) discontinuation of contact tracing; and 2) continuation of current control in combination with chemoprophylaxis. Both scenarios started in 2015 and were projected until 2050. RESULTS: The modelled NCDR in Pará State after 2014 shows a continuous downward trend, reaching the official elimination target of 10 cases per 100,000 population by 2030. The cessation of systematic contact tracing would not result in a higher NCDR in the long run. Systematic contact tracing in combination with chemoprophylaxis for contacts would reduce the NCDR by 40% and bring attainment of the elimination target two years forward to 2028. CONCLUSION: The NCDR of leprosy continues to decrease in Pará State. Elimination of leprosy as a public health problem could possibly be achieved around 2030, if the current control program is maintained. Providing chemoprophylaxis would decrease the NCDR further and would bring elimination forward by two years.

Constatación del papel de la búsqueda de contactos y estrategias de prevención en a interrupción de la transmisión de la Lepra - quimio profilaxis: llamamiento para pedir una mayor investigación / No disponible

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Protecting people against leprosy: chemoprophylaxis and immunoprophylaxis.

Elimination of leprosy cannot be achieved by multidrug therapy alone, and new tools are needed to prevent leprosy. A randomized controlled trial with chemoprophylaxis for contacts of leprosy patients using a single dose of rifampicin (SDR) has shown an overall protective effect of approximately 60%, effective in the first 2 years after the intervention. When a contact who previously received bacillus Calmette-Guérin (BCG) vaccination also receives SDR, the protective effect is additive, approximating 80%. Vaccine trials have been conducted with BCG, often in combination with Mycobacterium leprae or related Mycobacterium vaccines as immunoprophylaxis for contacts of leprosy patients, with BCG giving the best results. Meta-analysis shows that the protective effect of BCG vaccination is larger in observational studies than in trials, 60% versus 41%, and is higher among contacts of leprosy patients than among the general population, 68% versus 53%. We believe that a future leprosy control strategy should include contact management, consisting of a contact survey, at which time preventive interventions could be added, such as chemoprophylaxis and immunoprophylaxis. Modeling studies have shown that both interventions will lower the incidence of leprosy in the population. Implementation studies of such contact-based strategy are now called for.

Quimioprofilaxia de contatos de doentes de hanseníase com rifampicina em dose única / Chemoprophylaxis of contacts of leprosy patients with rifampicin in a single dose

INTRODUÇÃO: Na década de 1940, a dapsona tornou-se a droga de escolha para o tratamento da hanseníase. No início de 1980 ela foi incluída no tratamento com poliquimioterapia (PQT), resultado da combinação da rifampicina, dapsona e clofazimina, instituído no Brasil na década de 1990. Desde então, mais de 15 milhões de pacientes de hanseníase foram curados em todo o mundo, como resultado da implementação global da PQT/OMS para eliminação da hanseníase como problema de saúde pública. Quanto a taxa de incidência da hanseníase, representada pela taxa de detecção, ocorreu redução na maioria dos países endêmicos. No Brasil as taxas de detecção sofrem redução contínua e linear com média de 5% ao ano desde 2003. Para regiões mais endêmicas como Norte, Nordeste e Centre-Oeste ocorre declínio anual mais expressivo da detecção, no entanto permanecem muitas áreas com alta endemicidade. Para a vigilância epidemiológica da hanseníase ressalta-se o exame de contatos como principal atividade em razão da insuficiência da detecção de casos por demanda espontânea. A quimioprofilaxia oferecida aos contatos de casos conhecidos tem sido testada em várias protocolos, como uma intervenção para a redução da incidência da hanseníase. Um termo mais amplamente utilizado para a quimioprofilaxia e/ou imunoprofilaxia é "profilaxia pós-exposição (PEP)". A PEP pode ser usada para expressar quimioprofilaxia ou imunoprofilaxia, ou ainda, para ambas. DELIBERAÇÃO FINAL: Os membros da CONITEC presentes na reunião do plenário do dia 11/06/2015 deliberaram, por unanimidade, recomendar a incorporação da quimioprofilaxia de contato de doentes de hanseníase com rifampicina em dose única de acordo com estratégia de implantação do Ministério da Saúde. Foi assinado o Registro de Deliberação nº 127/2015. DECISÃO: PORTARIA Nº 32, de 30 de junho de 2015 - Torna pública a decisão de incorporar a quimioprofilaxia de contatos de doentes de hanseníase com rifampicina em dose única no âmbito do Sistema Único de Saúde - SUS.

Protecting people against leprosy: chemoprophylaxis and immunoprophylaxis

Elimination of leprosy cannot be achieved by multidrug therapy alone, and new tools are needed to prevent leprosy. A randomized controlled trial with chemoprophylaxis for contacts of leprosy patients using a single dose of rifampicin (SDR) has shown an overall protective effect of approximately 60%, effective in the first 2 years after the intervention. When a contact who previously received bacillus Calmette-Guérin (BCG) vaccination also receives SDR, the protective effect is additive, approximating 80%. Vaccine trials have been conducted with BCG, often in combination with Mycobacterium leprae or related Mycobacterium vaccines as immunoprophylaxis for contacts of leprosy patients, with BCG giving the best results. Meta-analysis shows that the protective effect of BCG vaccination is larger in observational studies than in trials, 60% versus 41%, and is higher among contacts of leprosy patients than among the general population, 68% versus 53%. We believe that a future leprosy control strategy should include contact management, consisting of a contact survey, at which time preventive interventions could be added, such as chemoprophylaxis and immunoprophylaxis. Modeling studies have shown that both interventions will lower the incidence of leprosy in the population. Implementation studies of such contact-based strategy are now called for.

Caso familiar intradomiciliario de lepra tuberculoide e índice lepromatoso / No disponible

La lepra es una enfermedad infecciosa crónica causada por Mycobacterium leprae, que tiene especial tropismo por la piel, las membranas mucosas y los nervios periféricos. En general, cuando se manifiesta en los niños menores de quince años refleja la intensidad y la larga exposición a una gran carga bacteriana.1 En Paraguay, según datos del Programa Nacional de Control de Lepra, en el año 2013 se reportaron 408 casos nuevos, lo que corresponde a una tasa de 6,11 casos por 100.000 habitantes, 394 casos (96,6%) en pacientes mayores de 15 años y 14 casos (3,4%) en pacientes menores de 15 años.2 Presentamos un caso de Lepra familiar, donde el diagnóstico de un hombre con Lepra Lepromatosa condujo a la investigación de sus contactos intra-domiciliarios, en quienes se diagnosticaron casos de Lepra Tuberculoide (en dos de sus tres hijos). Este reporte demuestra la importancia de la realización de una pesquisa activa entre los contactos de los pacientes, constituyéndose así en una herramienta imprescindible, tanto para el diagnóstico y el tratamiento tempranos, así como para prevenir secuelas y eliminar la enfermedad como problema de salud pública

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, which has special tropism for the skin, mucous membranes and peripheral nerves. In general, when it manifests in children under fifteen years old, reflects the intensity and long exposure to a high bacterial load.1 In Paraguay, according to the National Leprosy Control Programme, in the year 2013, 408 new cases were diagnosed, which corresponds to a rate of 6,11 cases per 100,000, 394 cases (96,6%) in patients older than 15 years old were reported, and 14 cases (3,4%) in patientsyounger than 15 years old.2 We present a case of family Leprosy, where the diagnosis of a man with Lepromatous Leprosy, led to the investigation of their household contacts, in which cases of Tuberculoid Leprosy were diagnosed in two of their three children. This report demonstrates the importance of conducting an active investigation between patient contacts, thus becoming an indispensable tool for both, the early diagnosis and treatment, as well as to prevent damage and eliminate the disease as a public health problem