Spatial distribution and temporal trends of leprosy in Uganda, 2012-2016: a retrospective analysis of public health surveillance data.

BACKGROUND: Leprosy is a neglected disease that poses a significant challenge to public health in Uganda. The disease is endemic in Uganda, with 40% of the districts in the country affected in 2016, when 42 out of 112 districts notified the National Tuberculosis and Leprosy Program (NTLP) of at least one case of leprosy. We determined the spatial and temporal trends of leprosy in Uganda during 2012-2016 to inform control measures. METHODS: We analyzed quarterly leprosy case-finding data, reported from districts to the Uganda National Leprosy Surveillance system (managed by NTLP) during 2012-2016. We calculated new case detection by reporting district and administrative regions of treatment during this period. New case detection was defined as new leprosy cases diagnosed by the Uganda health services divided by regional population; population estimates were based on 2014 census data. We used logistic regression analysis in Epi-Info version 7.2.0 to determine temporal trends. Population estimates were based on 2014 census data. We used QGIS software to draw choropleth maps showing leprosy case detection rates, assumed to approximate the new case detection rates, per 100,000 population. RESULTS: During 2012-2016, there was 7% annual decrease in reported leprosy cases in Uganda each year (p = 0.0001), largely driven by declines in the eastern (14%/year, p = 0.0008) and central (11%/year, p = 0.03) regions. Declines in reported cases in the western (9%/year, p = 0.12) and northern (4%/year, p = 0.16) regions were not significant. The combined new case detection rates from 2012 to 2016 for the ten most-affected districts showed that 70% were from the northern region, 20% from the eastern, 10% from the western and 10% from the central regions. CONCLUSION: There was a decreasing trend in leprosy new case detection in Uganda during 2012-2016; however, the declining trends were not consistent in all regions. The Northern region consistently identified more leprosy cases compared to the other regions. We recommend evaluation of the leprosy surveillance system to ascertain the leprosy situation.

Tuberculosis retreatment 'others' in comparison with classical retreatment cases; a retrospective cohort review.

BACKGROUND: Many of the countries in sub-Saharan Africa are still largely dependent on microscopy as the mainstay for diagnosis of tuberculosis (TB) including patients with previous history of TB treatment. The available guidance in management of TB retreatment cases is focused on bacteriologically confirmed TB retreatment cases leaving out those classified as retreatment 'others'. Retreatment 'others' refer to all TB cases who were previously treated but with unknown outcome of that previous treatment or who have returned to treatment with bacteriologically negative pulmonary or extra-pulmonary TB. This study was conducted in 11 regional referral hospitals (RRHs) serving high burden TB districts in Uganda to determine the profile and treatment success of TB retreatment 'others' in comparison with the classical retreatment cases. METHODS: A retrospective cohort review of routinely collected National TB and Leprosy Program (NTLP) facility data from 1 January to 31 December 2010. This study uses the term classical retreatment cases to refer to a combined group of bacteriologically confirmed relapse, return after failure and return after loss to follow-up cases as a distinct group from retreatment 'others'. Distribution of categorical characteristics were compared using Chi-squared test for difference between proportions. The log likelihood ratio test was used to assess the independent contribution of type of retreatment, human immunodeficiency virus (HIV) status, age group and sex to the models. RESULTS: Of the 6244 TB cases registered at the study sites, 733 (11.7%) were retreatment cases. Retreatment 'others' constituted 45.5% of retreatment cases. Co-infection with HIV was higher among retreatment 'others' (70.9%) than classical retreatment cases (53.5%). Treatment was successful in 410 (56.2%) retreatment cases. Retreatment 'others' were associated with reduced odds of success (AOR = 0.44, 95% CI 0.22,0.88) compared to classical cases. Lost to follow up was the commonest adverse outcome (38% of adverse outcomes) in all retreatment cases. Type of retreatment case, HIV status, and age were independently associated with treatment success. CONCLUSION: TB retreatment 'others' constitute a significant proportion of retreatment cases, with higher HIV prevalence and worse treatment success. There is need to review the diagnosis and management of retreatment 'others'.

A study on inclusion of leprosy in the curricula of pre-service health training institutions in Uganda.

OBJECTIVE: To establish the categories of pre-service health training institutions in Uganda that still maintain leprosy in their curricula and how leprosy training is organised. MATERIALS AND METHODS: A structured questionnaire was administered to the heads of 42 health training institutions including universities, paramedical and nurses' training schools. RESULTS: Leprosy was included in the curricula of 33 (78%) of the institutions studied but only 50% of them had organised leprosy training in the 2 years prior to the study. In 48% of cases the training was implemented by in-house trainers; the rest depended on external trainers and staff of a leprosy training centre. Course evaluation using a variety of methods was practiced by 80% of the institutions. CONCLUSIONS: Inclusion of leprosy in the curricula of pre-service health training institutions was not always followed by actual training. It is possible and acceptable to organise leprosy training within the confines of the institutions provided arrangements are made to include interaction with patients. Local leprosy control supervisors and dermatologists can be engaged to support pre-service training. In order to derive optimal benefit from this opportunity, the National Tuberculosis and Leprosy Control Programme should develop a national plan for leprosy training, organise training of trainers and assure access to appropriate teaching and learning materials. There is a need for more comprehensive evaluation of the ongoing leprosy training in pre-service institutions.

Potential role of dermatologists and dermatological services in developing and sustaining the leprosy control referral system in resource constrained settings.

General Health Services that pay due attention to the management of skin conditions are opportune for suspecting and diagnosing early leprosy. In many developing countries, patients with dermatological conditions can only access specialist services in the larger cities and university hospitals; unaffordable costs make the services even less accessible if they can only be provided in the private sector. The high profile of dermatologists in the health services, gives them the opportunity to facilitate the development and implementation of a referral system that includes leprosy. This potential benefit for leprosy control must be initiated by current National Leprosy Programme Managers through establishing formal relationships with the dermatologists and involving them and other partners in the re-designing of leprosy control strategies to keep them in tandem with changing epidemiological patterns, national policies and on -going health sector reforms. The same health service managers should avail of the opportunities from the dermatologists (both in public and private sectors) about the current knowledge on the management and control of leprosy.