Spatio-temporal analysis of leprosy risks in a municipality in the state of Mato Grosso-Brazilian Amazon: results from the leprosy post-exposure prophylaxis program in Brazil.

BACKGROUND: Leprosy post-exposure prophylaxis (LPEP) with single dose rifampicin (SDR) can be integrated into different leprosy control program set-ups once contact tracing has been established. We analyzed the spatio-temporal changes in the distribution of index cases (IC) and co-prevalent cases among contacts of leprosy patients (CP) over the course of the LPEP program in one of the four study areas in Brazil, namely the municipality of Alta Floresta, state of Mato Grosso, in the Brazilian Amazon basin. METHODS: Leprosy cases were mapped, and socioeconomic indicators were evaluated to explain the leprosy distribution of all leprosy cases diagnosed in the period 2016-2018. Data were obtained on new leprosy cases [Notifiable diseases information system (Sinan)], contacts traced by the LPEP program, and socioeconomic variables [Brazilian Institute of Geography and Statistics (IBGE)]. Kernel, SCAN, factor analysis and spatial regression were applied to analyze changes. RESULTS: Overall, the new case detection rate (NCDR) was 20/10 000 inhabitants or 304 new cases, of which 55 were CP cases among the 2076 examined contacts. Changes over time were observed in the geographic distribution of cases. The highest concentration of cases was observed in the northeast of the study area, including one significant cluster (Relative risk = 2.24; population 27 427, P-value < 0.001) in an area characterized by different indicators associated with poverty as identified through spatial regression (Coefficient 3.34, P-value = 0.01). CONCLUSIONS: The disease distribution was partly explained by poverty indicators. LPEP influences the spatial dynamic of the disease and results highlighted the relevance of systematic contact surveillance for leprosy elimination.

Reimagining leprosy elimination with AI analysis of a combination of skin lesion images with demographic and clinical data.

Background: Leprosy is an infectious disease that mostly affects underserved populations. Although it has been largely eliminated, still about 200'000 new patients are diagnosed annually. In the absence of a diagnostic test, clinical diagnosis is often delayed, potentially leading to irreversible neurological damage and its resulting stigma, as well as continued transmission. Accelerating diagnosis could significantly contribute to advancing global leprosy elimination. Digital and Artificial Intelligence (AI) driven technology has shown potential to augment health workers abilities in making faster and more accurate diagnosis, especially when using images such as in the fields of dermatology or ophthalmology. That made us start the quest for an AI-driven diagnosis assistant for leprosy, based on skin images. Methods: Here we describe the accuracy of an AI-enabled image-based diagnosis assistant for leprosy, called AI4Leprosy, based on a combination of skin images and clinical data, collected following a standardized process. In a Brazilian leprosy national referral center, 222 patients with leprosy or other dermatological conditions were included, and the 1229 collected skin images and 585 sets of metadata are stored in an open-source dataset for other researchers to exploit. Findings: We used this dataset to test whether a CNN-based AI algorithm could contribute to leprosy diagnosis and employed three AI models, testing images and metadata both independently and in combination. AI modeling indicated that the most important clinical signs are thermal sensitivity loss, nodules and papules, feet paresthesia, number of lesions and gender, but also scaling surface and pruritus that were negatively associated with leprosy. Using elastic-net logistic regression provided a high classification accuracy (90%) and an area under curve (AUC) of 96.46% for leprosy diagnosis. Interpretation: Future validation of these models is underway, gathering larger datasets from populations of different skin types and collecting images with smartphone cameras to mimic real world settings. We hope that the results of our research will lead to clinical solutions that help accelerate global leprosy elimination. Funding: This study was partially funded by Novartis Foundation and Microsoft (in-kind contribution).

Preventing leprosy with retrospective active case finding combined with single-dose rifampicin for contacts in a low endemic setting: results of the Leprosy Post-Exposure Prophylaxis program in Cambodia.

Post-exposure prophylaxis (PEP) with single-dose rifampicin (SDR) reduces the risk of developing leprosy among contacts of leprosy patients. Most evidence for the feasibility of the intervention is from highly endemic settings while low-endemic areas present unique challenges including reduced awareness of the disease among the population and in the health system, and the only sporadic occurrence of cases which together make defining any type of routine process challenging. We complemented the retrospective active case finding (RACF) approach with SDR administration to eligible contacts, and piloted the intervention across 31 operational districts in Cambodia. The aim was to demonstrate the feasibility of improving early case detection and administering SDR in a low endemic setting. The intervention focused on leprosy patients diagnosed since 2011 and was implemented between October 2016 - September 2019. The "drives" approach was employed to trace contacts: a trained team systematically contacted all eligible cases in a district, traced and screened contacts, and administered SDR. A total of 555 index patients were traced by the drive team, and 10,410 contacts in their household and 5 immediate neighbor houses listed. Among these contacts, 72.0% could be screened while most others were absent on the screening day. A total of 33 new leprosy cases were diagnosed and 6189 contacts received SDR (82.6% of the screened contacts). Sixty-one contacts refused SDR administration. We conclude that integrating PEP with SDR in RACF campaigns is feasible, and that this approach is appropriate in low resource and low endemic settings. Over time, evidence on whether or not the approach reduced leprosy transmission in Cambodia, may become clear.

The long-term impact of the Leprosy Post-Exposure Prophylaxis (LPEP) program on leprosy incidence: A modelling study.

BACKGROUND: The Leprosy Post-Exposure Prophylaxis (LPEP) program explored the feasibility and impact of contact tracing and the provision of single dose rifampicin (SDR) to eligible contacts of newly diagnosed leprosy patients in Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. As the impact of the programme is difficult to establish in the short term, we apply mathematical modelling to predict its long-term impact on the leprosy incidence. METHODOLOGY: The individual-based model SIMCOLEP was calibrated and validated to the historic leprosy incidence data in the study areas. For each area, we assessed two scenarios: 1) continuation of existing routine activities as in 2014; and 2) routine activities combined with LPEP starting in 2015. The number of contacts per index patient screened varied from 1 to 36 between areas. Projections were made until 2040. PRINCIPAL FINDINGS: In all areas, the LPEP program increased the number of detected cases in the first year(s) of the programme as compared to the routine programme, followed by a faster reduction afterwards with increasing benefit over time. LPEP could accelerate the reduction of the leprosy incidence by up to six years as compared to the routine programme. The impact of LPEP varied by area due to differences in the number of contacts per index patient included and differences in leprosy epidemiology and routine control programme. CONCLUSIONS: The LPEP program contributes significantly to the reduction of the leprosy incidence and could potentially accelerate the interruption of transmission. It would be advisable to include contact tracing/screening and SDR in routine leprosy programmes.

Leprosy post-exposure prophylaxis with single-dose rifampicin (LPEP): an international feasibility programme.

BACKGROUND: Innovative approaches are required for leprosy control to reduce cases and curb transmission of Mycobacterium leprae. Early case detection, contact screening, and chemoprophylaxis are the most promising tools. We aimed to generate evidence on the feasibility of integrating contact tracing and administration of single-dose rifampicin (SDR) into routine leprosy control activities. METHODS: The leprosy post-exposure prophylaxis (LPEP) programme was an international, multicentre feasibility study implemented within the leprosy control programmes of Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Tanzania. LPEP explored the feasibility of combining three key interventions: systematically tracing contacts of individuals newly diagnosed with leprosy; screening the traced contacts for leprosy; and administering SDR to eligible contacts. Outcomes were assessed in terms of number of contacts traced, screened, and SDR administration rates. FINDINGS: Between Jan 1, 2015, and Aug 1, 2019, LPEP enrolled 9170 index patients and listed 179 769 contacts, of whom 174 782 (97·2%) were successfully traced and screened. Of those screened, 22 854 (13·1%) were excluded from SDR mainly because of health reasons and age. Among those excluded, 810 were confirmed as new patients (46 per 10 000 contacts screened). Among the eligible screened contacts, 1182 (0·7%) refused prophylactic treatment with SDR. Overall, SDR was administered to 151 928 (86·9%) screened contacts. No serious adverse events were reported. INTERPRETATION: Post-exposure prophylaxis with SDR is safe; can be integrated into different leprosy control programmes with minimal additional efforts once contact tracing has been established; and is generally well accepted by index patients, their contacts, and health-care workers. The programme has also invigorated local leprosy control through the availability of a prophylactic intervention; therefore, we recommend rolling out SDR in all settings where contact tracing and screening have been established. FUNDING: Novartis Foundation.

Leprosy post-exposure prophylaxis with single-dose rifampicin (LPEP): an international feasibility programme

Background: Innovative approaches are required for leprosy control to reduce cases and curb transmission of Mycobacterium leprae. Early case detection, contact screening, and chemoprophylaxis are the most promising tools. We aimed to generate evidence on the feasibility of integrating contact tracing and administration of single-dose rifampicin (SDR) into routine leprosy control activities. Methods The leprosy post-exposure prophylaxis (LPEP) programme was an international, multicentre feasibility study implemented within the leprosy control programmes of Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Tanzania. LPEP explored the feasibility of combining three key interventions: systematically tracing contacts of individuals newly diagnosed with leprosy; screening the traced contacts for leprosy; and administering SDR to eligible contacts. Outcomes were assessed in terms of number of contacts traced, screened, and SDR administration rates. Findings Between Jan 1, 2015, and Aug 1, 2019, LPEP enrolled 9170 index patients and listed 179 769 contacts, of whom 174782 (97·2%) were successfully traced and screened. Of those screened, 22 854 (13·1%) were excluded from SDR mainly because of health reasons and age. Among those excluded, 810 were confirmed as new patients (46 per 10 000 contacts screened). Among the eligible screened contacts, 1182 (0·7%) refused prophylactic treatment with SDR. Overall, SDR was administered to 151 928 (86·9%) screened contacts. No serious adverse events were reported. Interpretation Post-exposure prophylaxis with SDR is safe; can be integrated into different leprosy control programmes with minimal additional efforts once contact tracing has been established; and is generally well accepted by index patients, their contacts, and health-care workers. The programme has also invigorated local leprosy control through the availability of a prophylactic intervention; therefore, we recommend rolling out SDR in all settings where contact tracing and screening have been established(AU).

The long-term impact of the leprosy post-exposure prophylaxis (LPEP) program on leprosy incidence: a modelling study

The Leprosy Post-Exposure Prophylaxis (LPEP) program explored the feasibility and impact of contact tracing and the provision of SDR to eligible contacts of newly diagnosed leprosy patients in states or districts of Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. This study investigated the long-term impact of the LPEP program on the leprosy new case detection rate (NCDR). Our results show that LPEP could reduce the NCDR beyond the impact of the routine leprosy control programme and that many new cases could be prevented. The benefit of LPEP increases gradually over time. LPEP could accelerate the time of reaching predicted NCDR levels of 2040 under routine program by up to six years. Furthermore, we highlighted how the impact varies between countries due to differences in the number of contacts per index patient screened and differences in leprosy epidemiology and national control programme. Generally, including both household contacts and neighbours (> 20 contacts per index patient) would yield the highest impact.

[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.

GPZL working group assesses challenges and a path forward for leprosy during COVID-19

GPZL Working Group 1, the Leprosy Emergency Operations Committee (LEOC), works to address and resolve drug-free problems for the treatment of leprosy and leprosy reactions

Prolaxis post-exposición para lepra con dosis única de rifampicina: manual para su implementación / Post-exposure prolaxis for leprosy with a single dose of rifampicin: a manual for its implementation

Objetivo: La profilaxis post-exposición de la lepra con dosis única de rifampicina (SDR-PEP) ha demostrado ser efectiva y aplicable y está recomendada por la OMS desde 2018. Esta caja de herramientas SDR-PEP se desarrolló a través de la experiencia de la profilaxis lepra post-eliminación (LPEP). Se ha diseñado para facilitar y estandarizar la implementación del seguimiento de contactos y la administración SDR-PEP en regiones y países que iniciaron la intervención. Resultados: Se desarrollaron cuatro instrumentos, incorporando la evidencia existente actual para SDR-PEP y los métodos y enseñanzas del proyecto LPEP en ocho países. (1) El conjunto de diapositivas Powerpoint política/apoyo que ayudarán a los programadores sobre la evidencia, practicabilidad y recursos necesarios para SDR-PEP, (2) La colección de diapositivas PowerPoint sobre formación e implementación en el campo para formar al personal implicado en el seguimiento de contactos y PEP con SDR, (3) manual genérico de campo SDR-PEP que puede ser usado para formar un protocolo específico de campo para el seguimiento de contactos y SDR-PEP como referencia para el personal directamente implicado. Finalmente, (4) el manual director SDR-PEP, que resume los distintos componentes de la caja de herramientas y contiene las instrucciones para su uso. Conclusión: En respuesta al interés manifestado por varios países de implementar el seguimiento de contactos de lepra con PEP con SDR, con las recomendaciones OMS sobre SDR-PEP, esta caja de herramientas basada en la evidencia concreta pero flexible, ha sido diseñada para servir a los directores de programas nacionales de lepra con un medio práctico para trasladar los planteamientos a la práctica. Está disponible gratuitamente en la página de Infolep y actualizada constantemente: https://www.leprosy-information.org/keytopic/leprosy-post-exposure-prophylaxis-lpep-programme(AU).

Objective: Leprosy post-exposure prophylaxis with single-dose rifampicin (SDRPEP) has proven effective and feasible, and is recommended by WHO since 2018. This SDR-PEP toolkit was developed through the experience of the leprosy post-exposure prophylaxis (LPEP) programme. It has been designed to facilitate and standardise the implementation of contact tracing and SDR-PEP administration in regions and countries that start the intervention. Results: Four tools were developed, incorporating the current evidence for SDRPEP and the methods and learnings from the LPEP project in eight countries. (1) the SDR-PEP policy/advocacy PowerPoint slide deck which will help to inform policy makers about the evidence, practicalities and resources needed for SDR-PEP, (2) the SDR-PEP field implementation training PowerPoint slide deck to be used to train front line staff to implement contact tracing and PEP with SDR, (3) the SDR-PEP generic field guide which can be used as a basis to create a location specific field protocol for contact tracing and SDR-PEP serving as a reference for frontline field staff. Finally, (4) the SDR-PEP toolkit guide, summarising the different components of the toolkit and providing instructions on its optimal use. Conclusion: In response to interest expressed by countries to implement contact tracing and leprosy PEP with SDR in the light of the WHO recommendation of SDRPEP, this evidence-based, concrete yet flexible toolkit has been designed to serve national leprosy programme managers and support them with the practical means to translate policy into practice. The toolkit is freely accessible on the Infolep homepages and updated as required: https://www.leprosy-information.org/keytopic/leprosy-postexposure-prophylaxis-lpep-programme(AU).

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).

Mínima Información esencial para documentar el seguimiento de contactos y dosis única de Rifampicina (SDR) para el control de la Lepra: Guía práctica / No disponible

Hay un renovado interés en el control de la lepra mediante la búsqueda activa de casos, que cada vez más se combina con intervenciones quimioprofilácticas para intentar reducir la transmisión del Mycobacterium leprae. El Programa Profilaxis Post-Exposición a la Lepra (LPEP, en inglés) está activo en ocho países endémicos e implementa la administración de dosis única de rifampicina (SDR, en inglés) a contactos seleccionados de pacientes de lepra. LPEP ha desarrollado un sistema de vigilancia, incluyendo la obtención de datos, reportes y controles rutinarios para cada país participante. Este sistema es todavía en gran parte específico para el programa LPEP. Para facilitar la continuidad después de completar la fase del proyecto y la puesta en marcha en otros países interesados, se intenta identificar la cantidad mínima de datos para documentar adecuadamente las actividades de la búsqueda de contactos y administración SDR para el control de la lepra de forma rutinaria. Se describen cuatro indicadores para el caso índice (además de cuatro ya obtenidos habitualmente) y siete indicadores para el cribaje de convivientes/contactos vecinos y encuestas comunitarias. Se proponen dos formas genéricas para obtener toda la información relevante a nivel de campo y distrito para el seguimiento de individuos o datos si resultara necesario, facilitar directrices para desarrollar las distintas tareas, proporcionar control de calidad al registrar las cuestiones clave para valorar la SDR y facilitar poder informar. Estos impresos genéricos tienen que adaptarse a requerimientos locales en cuanto a diseño, idioma e indicadores operacionales adicionales

In leprosy control there is a renewed interest in active case finding, which is increasingly being combined with chemoprophylactic interventions to try and reduce M. leprae transmission. The Leprosy Post-Exposure Prophylaxis (LPEP) programme, currently ongoing in eight endemic countries, pilots the provision of single-dose rifampicin (SDR) to eligible contacts of leprosy patients. LPEP has developed a surveillance system including data collection, reporting and regular monitoring for every participating country. This system is still largely programm-especific to LPEP. To facilitate continuity after completion of the project phase and start-up in other interested countries, we aim at identifying the minimal set of data required to appropriately document contact tracing activities and SDR administration for leprosy control in a routine setting. We describe four indicators for the index case (plus four already routinely collected) and seven indicators for household/neighbour screening, and community surveys. We propose two generic forms to capture all relevant information required at field and district level to follow-up on individuals or data if needed, provide guidance on the sequence of tasks, provide quality control by listing key questions to assess SDR eligibility, and facilitate reporting. These generic forms have to be adapted to local requirements in terms of layout, language, and additional operational indicators

Programa post-exposición a la profilaxis de la Lepra (LPEP): Actualización y análisis interno / No disponible

Se requieren nuevos planteamientos para incrementar el control de la lepra, disminuir el número de personas afectadas y cortar la transmisión. Para conseguir este objetivo las mejores soluciones son la detección precoz. El cribaje de contactos y la quimioprofilaxis. El Programa Profilaxis Post-exposición a la Lepra (LPEP) ayuda a demostrar la viabilidad de integrar el rastreo de contactos y dosis única de rifampicina (SDR) en las actividades rutinarias de control de la enfermedad. El programa LPEP está implementado entre los programas de control de la lepra de Brasil, Camboya, India, Indonesia, Myanmar, Nepal, Sri Lanka y Tanzania. Se centra en tres objetivos: rastro de contactos de nuevos pacientes diagnosticados de lepra, cribaje de contactos y administración de SDR a los contactos seleccionados. Las adaptaciones de protocolos países-específicos se refieren a la definición de contacto, edad mínima para SDR y personal implicado. La calidad de la evidencia se mantiene mediante coordinación central, documentación detallada y supervisión. Ya se han completado alrededor de 2 años de trabajo de campo en siete países en julio de 2017. Los 5,941 pacientes índice registrados (89·4% de los registrados) han identificado un total de 123,311 contactos, de los cuales el 99·1% ha sido rastreado y cribado. De entre ellos, se identificaron 406 nuevos pacientes de lepra (329/100,000) y a 10,883 (8·9%) no se les administró SDR por diversos motivos. También 785 contactos (6·7%) rehusó tomar la profilaxis con SDR. En total, se administró SDR al 89·0% de los contactos registrados. La profilaxis post-exposición con SDR es segura; se puede integrar en los programas rutinarios de control de la lepra y es generalmente bien aceptada por el paciente índice, sus contactos y el personal sanitario. El programa también consigue estimular los programas locales de control de la lepra

Innovative approaches are required to further enhance leprosy control, reduce the number of people developing leprosy, and curb transmission. Early case detection, contact screening, and chemoprophylaxis currently is the most promising approach to achieve this goal. The Leprosy Post-Exposure Prophylaxis (LPEP) programme generates evidence on the feasibility of integrating contact tracing and single-dose rifampicin (SDR) administration into routine leprosy control activities in different settings. The LPEP programme is implemented within the leprosy control programmes of Brazil, Cambodia, India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. Focus is on three key interventions: tracing the contacts of newly diagnosed leprosy patients; screening the contacts for leprosy; and administering SDR to eligible contacts. Country-specific protocol adaptations refer to contact definition, minimal age for SDR, and staff involved. Central coordination, detailed documentation and rigorous supervision ensure quality evidence. Around 2 years of field work had been completed in seven countries by July 2017. The 5,941 enrolled index patients (89·4% of the registered) identified a total of 123,311 contacts, of which 99·1% were traced and screened. Among them, 406 new leprosy patients were identified (329/100,000), and 10,883 (8·9%) were excluded from SDR for various reasons. Also, 785 contacts (0·7%) refused the prophylactic treatment with SDR. Overall, SDR was administered to 89·0% of the listed contacts. Post-exposure prophylaxis with SDR is safe; can be integrated into the routines of different leprosy control programmes; and is generally well accepted by index patients, their contacts and the health workforce. The programme has also invigorated local leprosy control

Retrospective active case finding in Cambodia: An innovative approach to leprosy control in a low-endemic country.

Currently, leprosy control relies on the clinical diagnosis of leprosy and the subsequent administration of multidrug therapy (MDT). However, many health workers are not familiar with the cardinal signs of leprosy, particularly in low-endemic settings including Cambodia. In response, a new approach to early diagnosis was developed in the country, namely retrospective active case finding (RACF) through small mobile teams. In the frame of RACF, previously diagnosed leprosy patients are traced and their contacts screened through "drives". According to the available records, 984 of the 1,463 (67.3%) index patients diagnosed between 2001 and 2010 and registered in the national leprosy database were successfully traced in the period 2012-2015. Migration (8.4%), death (6.7%), operational issues (1.6%) and unidentified other issues (16.0%) were the main reasons for non-traceability. A total of 17,134 contacts of traced index patients (average: 2.2 household members and 15.2 neighbors) and another 7,469 contacts of the untraced index patients could be screened. Among them, 264 new leprosy patients were diagnosed. In the same period, 1,097 patients were diagnosed through the routine passive case detection system. No change was observed in the relation between the rate at which new patients were identified and the number of years since the diagnosis of the index patient. Similar to leprosy patients diagnosed through passive case detection, the leprosy patients detected through RACF were predominantly adult males. However, the fraction of PB leprosy patients was higher among the patients diagnosed through RACF, suggesting relatively earlier diagnosis. It appears that RACF is a feasible option and effective in detecting new leprosy patients among contacts of previously registered patients. However, a well-maintained national leprosy database is essential for successful contact tracing. Hence, passive case detection in the frame of routine leprosy surveillance is a precondition for efficient RACF as the two systems are mutually enhancing. Together, the two approaches may offer an interesting option for countries with low numbers of leprosy patients but evidence of ongoing transmission. The impact on leprosy transmission could be further increased by the administration of single dose rifampicin as post-exposure prophylaxis to eligible contacts.

The Leprosy Post-Exposure Prophylaxis (LPEP) programme: update and interim analysis.

Innovative approaches are required to further enhance leprosy control, reduce the number of people developing leprosy, and curb transmission. Early case detection, contact screening, and chemoprophylaxis currently is the most promising approach to achieve this goal. The Leprosy Post-Exposure Prophylaxis (LPEP) programme generates evidence on the feasibility of integrating contact tracing and single-dose rifampicin (SDR) administration into routine leprosy control activities in different settings. The LPEP programme is implemented within the leprosy control programmes of Brazil, Cambodia, India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. Focus is on three key interventions: tracing the contacts of newly diagnosed leprosy patients; screening the contacts for leprosy; and administering SDR to eligible contacts. Country-specific protocol adaptations refer to contact definition, minimal age for SDR, and staff involved. Central coordination, detailed documentation and rigorous supervision ensure quality evidence. Around 2 years of field work had been completed in seven countries by July 2017. The 5,941 enrolled index patients (89·4% of the registered) identified a total of 123,311 contacts, of which 99·1% were traced and screened. Among them, 406 new leprosy patients were identified (329/100,000), and 10,883 (8·9%) were excluded from SDR for various reasons. Also, 785 contacts (0·7%) refused the prophylactic treatment with SDR. Overall, SDR was administered to 89·0% of the listed contacts. Post-exposure prophylaxis with SDR is safe; can be integrated into the routines of different leprosy control programmes; and is generally well accepted by index patients, their contacts and the health workforce. The programme has also invigorated local leprosy control.

Leprosy Post-Exposure Prophylaxis (LPEP) programme: study protocol for evaluating the feasibility and impact on case detection rates of contact tracing and single dose rifampicin.

INTRODUCTION: The reported number of new leprosy patients has barely changed in recent years. Thus, additional approaches or modifications to the current standard of passive case detection are needed to interrupt leprosy transmission. Large-scale clinical trials with single dose rifampicin (SDR) given as post-exposure prophylaxis (PEP) to contacts of newly diagnosed patients with leprosy have shown a 50-60% reduction of the risk of developing leprosy over the following 2 years. To accelerate the uptake of this evidence and introduction of PEP into national leprosy programmes, data on the effectiveness, impact and feasibility of contact tracing and PEP for leprosy are required. The leprosy post-exposure prophylaxis (LPEP) programme was designed to obtain those data. METHODS AND ANALYSIS: The LPEP programme evaluates feasibility, effectiveness and impact of PEP with SDR in pilot areas situated in several leprosy endemic countries: India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. Complementary sites are located in Brazil and Cambodia. From 2015 to 2018, contact persons of patients with leprosy are traced, screened for symptoms and assessed for eligibility to receive SDR. The intervention is implemented by the national leprosy programmes, tailored to local conditions and capacities, and relying on available human and material resources. It is coordinated on the ground with the help of the in-country partners of the International Federation of Anti-Leprosy Associations (ILEP). A robust data collection and reporting system is established in the pilot areas with regular monitoring and quality control, contributing to the strengthening of the national surveillance systems to become more action-oriented. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the relevant ethics committees in the countries. Results and lessons learnt from the LPEP programme will be published in peer-reviewed journals and should provide important evidence and guidance for national and global policymakers to strengthen current leprosy elimination strategies.

Negligible risk of inducing resistance in Mycobacterium tuberculosis with single-dose rifampicin as post-exposure prophylaxis for leprosy.

Post-exposure prophylaxis (PEP) for leprosy is administered as one single dose of rifampicin (SDR) to the contacts of newly diagnosed leprosy patients. SDR reduces the risk of developing leprosy among contacts by around 60 % in the first 2-3 years after receiving SDR. In countries where SDR is currently being implemented under routine programme conditions in defined areas, questions were raised by health authorities and professional bodies about the possible risk of inducing rifampicin resistance among the M. tuberculosis strains circulating in these areas. This issue has not been addressed in scientific literature to date. To produce an authoritative consensus statement about the risk that SDR would induce rifampicin-resistant tuberculosis, a meeting was convened with tuberculosis (TB) and leprosy experts. The experts carefully reviewed and discussed the available evidence regarding the mechanisms and risk factors for the development of (multi) drug-resistance in M. tuberculosis with a view to the special situation of the use of SDR as PEP for leprosy. They concluded that SDR given to contacts of leprosy patients, in the absence of symptoms of active TB, poses a negligible risk of generating resistance in M. tuberculosis in individuals and at the population level. Thus, the benefits of SDR prophylaxis in reducing the risk of developing leprosy in contacts of new leprosy patients far outweigh the risks of generating drug resistance in M. tuberculosis.