Individual and community factors determining delayed leprosy case detection: A systematic review.

BACKGROUND: The number of new leprosy cases is declining globally, but the disability caused by leprosy remains an important disease burden. The chance of disability is increased by delayed case detection. This review focusses on the individual and community determinants of delayed leprosy case detection. METHODS: This study was conducted according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). The study protocol is registered in PROSPERO (code: CRD42020189274). To identify determinants of delayed detection, data was collected from five electronic databases: Embase.com, Medline All Ovid, Web of Science, Cochrane CENTRAL, and the WHO Global Health Library. RESULTS: We included 27 papers from 4315 records assessed. They originated in twelve countries, had been published between January 1, 2000, and January 31, 2021, and described the factors related to delayed leprosy case detection, the duration of the delayed case, and the percentage of Grade 2 Disability (G2D). The median delay in detection ranged from 12 to 36 months, the mean delay ranged from 11.5 to 64.1 months, and the percentage of G2D ranged from 5.6 to 43.2%. Health-service-seeking behavior was the most common factor associated with delayed detection. The most common individual factors were older age, being male, having a lower disease-symptom perception, having multibacillary leprosy, and lack of knowledge. The most common socioeconomic factors were living in a rural area, performing agricultural labor, and being unemployed. Stigma was the most common social and community factor. CONCLUSIONS: Delayed leprosy case detection is clearly correlated with increased disability and should therefore be a priority of leprosy programs. Interventions should focus on determinants of delayed case detection such as health-service-seeking behavior, and should consider relevant individual, socioeconomic, and community factors, including stigmatization. Further study is required of the health service-related factors contributing to delay.

Risk of disability among adult leprosy cases and determinants of delay in diagnosis in five states of India: A case-control study.

INTRODUCTION: A high proportion of grade 2 disability (visible deformity) is indicative of delay in detection of leprosy and leprosy is one of the major causes of preventable disability. We conducted this study to determine the risk factors associated with disability (G2D and G1D) among adult new leprosy cases and to measure their strength of association. METHODS: A multi-centric case-control study was undertaken in five states of India i.e. Andhra Pradesh, Delhi, Gujarat, Maharashtra and West Bengal). Among new adult patients, cases were defined as those with disability (G2D and G1D) at the time of diagnosis and controls were defined as those without any disability (G0D). Delays were quantified based on patient recall across a timeline. Patient delay defined as the time period between first noticed symptom by the patient and the first visit to any health care provider (HCP); HCP delay defined as the time period between patient's first visit to any HCP and the confirmation of diagnosis of leprosy; and total delay defined as the sum of both patient and HCP delays. RESULTS: A total of 1400 new leprosy patients (700 G2D/G1D and 700 G0D) across five states were interviewed. Among G2D/G1D, the median patient delay was 8 months compared with 4 months among G0D. The median HCP delay was 2 months for G2D/G1D and 1 month for G0D. The median total delay was 14 months for G2D/G1D and 6.2 months for G0D; observed median difference between groups was statistically significant (p<0.001). When patient delay was more than 3 months, odds of G2D/G1D at diagnosis were 1.6 times higher compared to when patient delay was less than 3 months. When the HCP delay was more than one month, the odds of G2D/G1D were 1.4 times higher compared to when the HCP delay was less than one month. When the patient had multi-bacillary type leprosy the odds of G2D/G1D at the time of diagnosis was nine times higher compared to pauci-bacillary type leprosy. CONCLUSION: Patient delay is the major reason for risk of disability (G2D/G1D) among adult leprosy patients. A patient delay of more than 3 months from the notice of first symptom is a significant indicator for the disabilities among adult leprosy patients. Early case detection campaigns like active surveys in endemic spots should be done periodically as this can reduce delays and promote early diagnosis. Additionally, the program should lay greater emphasis on raising community awareness regarding the disease. Also, health care provider delay of more than 1 month have been significant risk factors for disability among adult leprosy cases. Hence, periodical capacitation of all HCPs including private practitioners would significantly contribute to reduce diagnostic delay and promote timely referral and early detection.

Gridlock from diagnosis to treatment of multidrug-resistant tuberculosis in Tanzania: low accessibility of molecular diagnostic services and lack of healthcare worker empowerment in 28 districts of 5 high burden TB regions with mixed methods evaluation.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) outcomes are adversely impacted by delay in diagnosis and treatment. METHODS: Mixed qualitative and quantitative approaches were utilized to identify healthcare system related barriers to implementation of molecular diagnostics for MDR-TB. Randomly sampled districts from the 5 highest TB burden regions were enrolled during the 4th quarter of 2016. District TB & Leprosy Coordinators (DTLCs), and District AIDS Coordinators (DACs) were interviewed, along with staff from all laboratories within the selected districts where molecular diagnostics tests for MDR-TB were performed. Furthermore, the 2015 registers were audited for all drug-susceptible but retreatment TB cases and TB collaborative practices in HIV clinics, as these patients were in principal targeted for drug susceptibility testing by rapid molecular diagnostics. RESULTS: Twenty-eight TB districts from the 5 regions had 399 patients reviewed for retreatment with a drug-susceptible regimen. Only 160 (40%) had specimens collected for drug-susceptibility testing, and of those specimens only 120 (75%) had results communicated back to the clinic. MDR-TB was diagnosed in 16 (13.3%) of the 120 specimens but only 12 total patients were ultimately referred for treatment. Furthermore, among the HIV/AIDS clinics served in 2015, the median number of clients with TB diagnosis was 92 cases [IQR 32-157] yet only 2 people living with HIV were diagnosed with MDR-TB throughout the surveyed districts. Furthermore, the districts generated 53 front-line healthcare workers for interviews. DTLCs with intermediate or no knowledge on the clinical application of XpertMTB/RIF were 3 (11%), and 10 (39%), and DACs with intermediate or no knowledge were 0 (0%) and 2 (8%) respectively (p = 0.02). Additionally, 11 (100%) of the laboratories surveyed had only the 4-module XpertMTB/RIF equipment. The median time that XpertMTB/RIF was not functional in the 12 months prior to the investigation was 2 months (IQR 1-4). CONCLUSIONS: Underutilization of molecular diagnostics in high-risk groups was a function of a lack of front-line healthcare workforce empowerment and training, and a lack of equipment access, which likely contributed to the observed delay in MDR-TB diagnosis in Tanzania.

Estudio de niños afectados de lepra sin tartar y con discapacidades de grado 2, registrados en un centro de referencia de bengala occidental, India / No disponible

Antecedente: Estudio observacional de niños diagnosticados con lepra y discapacidades Grado 2 en un centro de referencia en Bengala Occidental, India. Métodos: Se llevó a cabo un estudio descriptivo de 21 niños, diagnosticados como nuevos casos de lepra con discapacidad Grado 2 (G2D) y registrados para el tratamiento en el Leprosy Mission Hospital, Purulia, Bengala Occidental, India. Los detalles socio-demográficos y médicos se obtuvieron de las gráficas de los pacientes. Se entrevistaron tanto a padres como a niños para inquirir sobre los factores responsables del retraso en el diagnóstico. Resultados: Durante un período de 3 años (2013-15), se diagnosticaron 1938 personas como nuevos casos activos de lepra en nuestro centro de referencia; entre los pacientes registrados, 319 (16·5%) eran niños con edades comprendidas entre los 4 y los 15 años, de los cuales 159 (50%) fueron diagnosticados de tipo multibacilar y 21 (6·6%) presentaron ya discapacidades G2D. El porcentaje de discapacidad era menor en niños comparado con los adultos y mayor en niños MB que PB. Se detectó parálisis del músculo intrínseco de la mano en 15 niños y de entre ellos, 10 con parálisis del cubital de la mano derecha y tres con parálisis mediano-cubital bilateral. Varios niños habían detectado una mácula como primer síntoma y en 15 alguno de los padres estaba afectado. Conclusión: Este trabajo pone de manifiesto que todavía hay un problema con niños que desarrollan G2D antes del diagnóstico y señala algún de los factores sociales responsables del retraso en el diagnóstico e implementación de la MDT. Se necesita mejorar la comunicación y los métodos para persuadir a las familias a que se presenten pronto e implementar el tratamiento cuanto antes

Setting: An observational study of children diagnosed with leprosy and Grade 2 disability at a referral centre in West Bengal, India. Methods: A descriptive study was conducted of 21 children, diagnosed as new cases of leprosy with Grade 2 disability (G2D), and registered for treatment at The Leprosy Mission Hospital, Purulia, West Bengal, India. The socio-demographic and medical details were obtained from the patients’ charts. In-depth interviews were carried out with both the children and their parents to inquire about the factors responsible for the delay in diagnosis. Results: During a 3-year study period (2013-15), 1938 people were diagnosed as new active cases of leprosy at our referral centre; among the registered patients, 319 (16·5%) were children aged between 4 and 15 years, of whom 159 (50%) were diagnosed with multibacillary disease and 21 (6·6%) were reported with G2D. The disability proportion was lower in children compared with adults and higher in MB children compared with PB children. Paralysis of the intrinsic muscles of the hand was seen in 15 children and of these, 10 children had right hand ulnar paralysis and three had bilateral ulnar-median paralysis. Several children had noticed a patch as the first symptom and 15 had a leprosy-affected parent. Conclusion: This study shows that there is still a problem of children developing G2D before the diagnosis of leprosy is made, and points to some of the social factors responsible for delayed reporting and prompt starting of MDT. Better communication and innovative methods of persuading the families to report early need to be tested and urgently implemented