The geographical distribution and socioeconomic risk factors of COVID-19, tuberculosis and leprosy in Fortaleza, Brazil.

BACKGROUND: Fortaleza (Brazil) is high endemic for coronavirus disease 2019 (COVID-19), tuberculosis (TB) and leprosy. These three diseases share respiratory droplets through coughing or sneezing as the main mode of transmission but differ in incubation time, with COVID-19 having a short and leprosy a long incubation time. Consequently, contacts of a patient are at higher risk of infection and developing these diseases. There might be scope for combined preventive measures, but a better understanding of the geographical distribution and relevant socioeconomic risk factors of the three diseases is needed first. This study aims to describe the geographic distribution of COVID-19, TB and leprosy incidence and to identify common socioeconomic risk factors. METHODS: The total number of new cases of COVID-19, TB and leprosy, as well as socioeconomic and demographic variables, were retrieved from official registers. The geographical distribution of COVID-19, TB and leprosy rates per neighbourhood was visualised in Quantum GIS, and spatial autocorrelation was measured with Moran's I in GeoDa. A spatial regression model was applied to understand the association between COVID-19, TB, leprosy rates, and socioeconomic factors. RESULTS: COVID-19 and TB showed a more homogenous distribution, whereas leprosy is located more in the south and west of Fortaleza. One neighbourhood (Pedras) in the southeast was identified as high endemic for all three diseases. Literacy was a socioeconomic risk factor for all three diseases: a high literacy rate increases the risk of COVID-19, and a low literacy rate (i.e., illiteracy) increases the risk of TB and leprosy. In addition, high income was associated with COVID-19, while low income with TB. CONCLUSIONS: Despite the similar mode of transmission, COVID-19, TB and leprosy show a different distribution of cases in Fortaleza. In addition, associated risk factors are related to wealth in COVID-19 and to poverty in TB and leprosy. These findings may support policymakers in developing (partially combined) primary and secondary prevention considering the efficient use of resources.

Determining target populations for leprosy prophylactic interventions: a hotspot analysis in Indonesia.

BACKGROUND: Leprosy incidence remained at around 200,000 new cases globally for the last decade. Current strategies to reduce the number of new patients include early detection and providing post-exposure prophylaxis (PEP) to at-risk populations. Because leprosy is distributed unevenly, it is crucial to identify high-risk clusters of leprosy cases for targeting interventions. Geographic Information Systems (GIS) methodology can be used to optimize leprosy control activities by identifying clustering of leprosy cases and determining optimal target populations for PEP. METHODS: The geolocations of leprosy cases registered from 2014 to 2018 in Pasuruan and Pamekasan (Indonesia) were collected and tested for spatial autocorrelation with the Moran's I statistic. We did a hotspot analysis using the Heatmap tool of QGIS to identify clusters of leprosy cases in both areas. Fifteen cluster settings were compared, varying the heatmap radius (i.e., 500 m, 1000 m, 1500 m, 2000 m, or 2500 m) and the density of clustering (low, moderate, and high). For each cluster setting, we calculated the number of cases in clusters, the size of the cluster (km2), and the total population targeted for PEP under various strategies. RESULTS: The distribution of cases was more focused in Pasuruan (Moran's I = 0.44) than in Pamekasan (0.27). The proportion of total cases within identified clusters increased with heatmap radius and ranged from 3% to almost 100% in both areas. The proportion of the population in clusters targeted for PEP decreased with heatmap radius from > 100% to 5% in high and from 88 to 3% in moderate and low density clusters. We have developed an example of a practical guideline to determine optimal cluster settings based on a given PEP strategy, distribution of cases, resources available, and proportion of population targeted for PEP. CONCLUSION: Policy and operational decisions related to leprosy control programs can be guided by a hotspot analysis which aid in identifying high-risk clusters and estimating the number of people targeted for prophylactic interventions.

The impact of leprosy on the mental wellbeing of leprosy-affected persons and their family members - a systematic review.

Leprosy has long-term consequences related to impairment and stigma. This includes a major impact on mental health. This study aims to consolidate current evidence regarding the mental health impact of leprosy on affected persons and their family members. In addition, determinants influencing mental health outcomes among leprosy-affected persons and effective interventions are examined. A keyword-based search was conducted in PubMed, Web of Science, Scopus, PsycINFO, Infolep and InfoNTD; additional literature was also considered. Articles presenting primary data involving leprosy-affected persons or their family members experiencing mental conditions were included. Independent extraction of articles was executed using predefined data fields. Articles were sorted according to relevance. In total, 65 studies were included in this systematic review. Multiple psychiatric morbidities have been identified among leprosy-affected persons, including depression, anxiety disorders and suicide (attempts). Additional factors were found that may impact mental health. Moreover, studies found that demographic factors, lifestyle and disease-specific factors and stigma and discrimination impact mental health. Depressive symptoms and low self-esteem were identified among children of leprosy-affected persons. In addition, interventions were identified that could improve the mental wellbeing of leprosy patients. Depressive disorders and anxiety disorders were found to be very common among persons affected by leprosy. Feelings such as fear, shame and low self-esteem are also experienced by those affected, and their children. Further research is necessary to ensure that mental health impact is included when determining the burden of disease for leprosy, and to relieve this burden.

'People like me don't make things like that': Participatory video as a method for reducing leprosy-related stigma.

The Stigma Assessment and Reduction of Impact project aims to assess the effectiveness of stigma-reduction interventions in the field of leprosy. Participatory video seemed to be a promising approach to reducing stigma among stigmatized individuals (in this study the video makers) and the stigmatisers (video audience). This study focuses on the video makers and seeks to assess the impact on them of making a participatory video and to increase understanding of how to deal with foreseeable difficulties. Participants were selected on the basis of criteria and in collaboration with the community health centre. This study draws on six qualitative methods including interviews with the video makers and participant observation. Triangulation was used to increase the validity of the findings. Two videos were produced. The impact on participants ranged from having a good time to a greater sense of togetherness, increased self-esteem, individual agency and willingness to take action in the community. Concealment of leprosy is a persistent challenge, and physical limitations and group dynamics are also areas that require attention. Provided these three areas are properly taken into account, participatory video has the potential to address stigma at least at three levels - intrapersonal, interpersonal and community - and possibly more.

Development and structural validation of a shortened version of the Participation Scale.

PURPOSE: To validate a shortened version of the Participation Scale (P-scale) that will be quicker to use and to describe the factor structure found in the P-scale data in various study samples. METHODS: A large multi-country and multi-cultural database was compiled consisting of 5125 respondents. Item analysis, explanatory factor analysis and confirmatory factor analysis were applied to identify items for deletion and investigate the factor structure of the P-scale. RESULTS: The multi-country database included 11 databases from six different countries. Respondents were affected by a range of health conditions, including leprosy, HIV/AIDS, dermatological conditions and various disabilities. Of the respondents included 57% were male. The P-scale Short (PSS) contains 13 items. A two-factor structure, with factors named "work-related participation" (three items) and "general participation" (10 items), showed the best model fit (Comparative Fit Index = 0.983, Tucker Lewis Index = 0.979, Rooted Mean Square Error of Approximation = 0.061). The Cronbach's alphas were very good for both the whole scale and the subscales, 0.91, 0.83 and 0.90, respectively. Correlation between the two factors was high (r = 0.75) indicating that interpreting the P-scale as measuring an overall factor "participation" is still valid. A very high correlation (r = 0.99) was found between the full P-scale and the PSS. CONCLUSIONS: The findings suggest good validity of the P-scale across a range of languages and cultures. However, field testing needs to confirm the validity of the PSS to measure the level of social participation restrictions across cultures and health conditions.

Stigma and social participation in Southern India: differences and commonalities among persons affected by leprosy and persons living with HIV/AIDS.

Stigma is a common phenomenon worldwide and infectious diseases like HIV/AIDS and leprosy are often associated with high levels of stigma. Several studies have been conducted concerning the effects of stigma and the impact on social participation, but comparative studies are rare. The objective of this study was to identify differences and similarities between HIV/AIDS and leprosy-related stigma. From April till July 2009, 190 questionnaire-based interviews were conducted to assess the levels of internalized stigma (Internalized Stigma of Mental Illness scale), perceived stigma (Explanatory Model Interview Catalogue stigma scale) and social participation (Participation scale) in a cross-sectional sample of people affected by leprosy (PL) and people living with HIV/AIDS (PLHA). Respondents were selected from several hospitals, charity projects and during home visits in Vellore district, Tamil Nadu. Our results showed that both PLHA (n = 95) and leprosy-affected respondents (n = 95) faced a substantial burden of internalized and perceived stigma, with the former reporting a significantly higher level of stigma. As a result, PLHA faced more frequent and also more severe participation restrictions than PL. Especially, restrictions in work-related areas were reported by the majority of the respondents. In conclusion, PLHA faced a significantly higher level of stigma and participation restriction than PL. However, the latter also reported a substantial burden of stigma and participation restrictions. The study suggests that it may be possible to develop joint interventions based on the commonalities found. More research is needed to define these more precisely and to test the effectiveness of such joint interventions in reducing stigma and improving social participation.

Risk factors for participation restriction in leprosy and development of a screening tool to identify individuals at risk.

The World Health Organisation International Classification of Functioning, Disability and Health defines participation as involvement in a life situation. Participation restrictions are problems experienced in any life situation, for example, in relationships or in employment. Our research explored risk factors for participation restrictions experienced by people affected by leprosy. Our objective was to develop a screening tool to identify individuals at risk. An initial round of qualitative fieldwork in eight centres in Nepal, India and Brazil identified 35 potential risk factors for participation restriction. These were then further assessed through quantitative fieldwork in six centres in India and Brazil. In all, 264 individuals receiving leprosy treatment or rehabilitation services made a retrospective assessment of their status at time of diagnosis. Their level of participation restriction was assessed using the Participation Scale. Regression analysis identified risk factors for participation restriction including fear of abandonment by family members (odds ratio 2.63, 95% CI 1.35-5.13) and hospitalization at diagnosis (3.98, 1.0-7.32). We recommend four consolidated items as the basis for a simple screening tool to identify individuals at risk. These are the physical impact of leprosy, an emotional response to the diagnosis, female gender and having little or no education. Such a tool may form the basis for a screening and referral procedure to identify newly diagnosed individuals at risk of participation restrictions and in need of actions that may prevent such restrictions.

Peripheral neuropathy in leprosy and its consequences.

Leprosy causes a 'mononeuritis multiplex' of immunological origin that results in autonomic, sensory and motor neuropathy. When detected and treated early, primary impairments may be reversible. However, 11-51% of patients do not recover. In addition, 33-56% of newly registered patients already have clinically detectable impairments, often no longer amenable to drug treatment. Among new patients, 6-27% present with secondary impairments, such as wounds, contractures and shortening of digits. All patients with impairments should be taught methods to prevent further impairment and subsequent disability (POID). As the result of impairments, many people experience limitation of activities of daily living, which can be partially overcome with the help of assistive devices, training, and surgery. As a result of these limitations, because of visible impairments, or simply because of the diagnosis 'leprosy', many people are restricted in their participation in society. Many overcome activity limitations and participation restrictions without assistance, despite residual impairments. However, some require intervention, such as physical or occupational therapy, reconstructive surgery or temporary socioeconomic assistance. Information on these issues is not collected routinely, and the few tools that exist to measure the severity or extent of impairment have not been widely used, nor have they been used to generate cohort-based statistics. There are no agreed indicators for monitoring POID activities or rehabilitation interventions. Work in the general field of rehabilitation has resulted in the ICIDH-2, which provides a conceptual framework for rehabilitation and the entire area of 'consequences of health conditions'. Although experience to date is very limited, the conceptual framework appears appropriate to leprosy. Data on the prevalence and incidence of primary and secondary impairments have been reported from several countries, the link between impairments and activity limitations has been investigated, and a few studies of the magnitude of the need for rehabilitation have been reported. Research priorities include studies of methods to improve detection of autonomic, sensory and motor neuropathy; trials of alternative drugs or regimens for treating neuropathy; studies of the use of various POID-monitoring systems that may be derived from these; studies of the design and use of instruments to assess limitations of activities and restrictions on participation; assessments of needs for rehabilitation and the development of methods to do these; studies of the efficacy of various types of rehabilitation interventions for particular conditions; and studies of the cost-effectiveness of such interventions.

A scale to assess activities of daily living in persons affected by leprosy.

The aim of this study was to develop a scale for identifying disability among people in the rural areas of developing countries. The studies were carried out in the Green Pastures Hospital and the leprosy field programme of the Western Region of Nepal. With the help of staff experienced in working with people with disability, a 68-question questionnaire was made, based on the International Classification of Impairments, Activities and Participation (ICIDH-2). A survey was carried out of 269 people affected by leprosy who had impairments, as well as a sample of those who were unimpaired. The survey results were used to develop the questionnaire into a scale, using standard scale development methods. This included checking of criterion validity, discrimination and reliability and stability using weighted kappa statistics. Of the 68 questions, 38 were included in the second draft of the instrument. Eight questions were added to identify difficulty in relationships, about the use of aids and about occupation and employment. The sum score of the scale against the expert score gave a Spearman correlation coefficient of 0.72. Intra- and inter-interviewer reliability coefficients were 0.77 (95% CI 0.73-0.81) and 0.61 (95% CI 0.56-0.67), respectively. The stability test gave an overall kappa of 0.76 (95% CI 0.70-0.82). Four questions with particularly poor results were omitted from the final draft of the instrument. An interview-based instrument was developed for identifying limitations in activities of daily living (disability) in people living in a rural setting in a developing country--the Green Pastures Activity Scale (GPAS). The scale performed well during validity and reliability testing. It consists of 34 activity questions, five relationship questions, and three questions on the use of aids, occupation and employment.

Grading impairment in leprosy.

The aim of the paper is to discuss the concept of 'severity grading' in relation to impairment in leprosy, and to describe the use of an impairment sum score, the Eyes, Hands, Feet (EHF) score, as an indicator of the severity and the evolution of impairment over time. The use of an impairment sum score, the EHF score, is illustrated using data on impairment at diagnosis and after a 2-year interval from MB patients released from MDT in the Western Region of Nepal. The WHO 1988 'disability' grading scale (0-2, for both eyes, hands and feet--six sites) was used as a measure of impairment. For the analysis, the WHO grades for the six sites were summed to form an EHF score (minimum 0, maximum 12). The sensitivity to change over time of the EHF score was compared with that of the 'method of maximum grades'. Using the 'method of maximum grades', 509/706 patients (72%) appeared not to have changed in impairment status, compared with only 399 (56.5%) with the EHF score. Improvement or deterioration of impairment status was missed in 113 patients (16%). In 216/706 patients (30.6%), the changes detected with the EHF score were bigger than those revealed by the method of maximum grades. The six components of the WHO impairment grading may be added up to form a EHF sum score of impairment. This score can be used to monitor changes in impairment status in individuals or in groups. It should be recorded and reported at least at diagnosis and release from treatment. Reporting could be done as the 'proportion of patients with improved EHF score', 'stable EHF score' and 'EHF score worse', and 'proportion of patients without impairment', 'proportion with WHO grade 1' and 'proportion with WHO grade 2'. It is recommended that the concepts and terminology of the WHO International Classification of Impairments, Activities and Participation (ICIDH-2) be adopted in the field of leprosy, particularly for the areas of prevention of impairment and disability and rehabilitation. The 'WHO disability grade' should be renamed 'WHO impairment grade'.

Intertester reliability of manual muscle strength testing in leprosy patients.

This study reports the results of a study on the intertester reliability of manual muscle strength testing in leprosy patients with confirmed motor function loss of at least one nerve. Three testers graded the muscle strength of 72 patients in random order. Both hands and feet were graded. Strength was graded on a modified Medical Research Council Scale (9 points, 5, 4+, 4, 3+, 3, 2+, 2, 1, 0). The following movements were tested for strength: little finger and index finger abduction, intrinsic position of all four fingers, thumb abduction and opposition, foot dorsiflexion and eversion and extension of the big toe. The weighted kappa statistic was used to calculate the chance-corrected percentage of agreement between observers. Overall agreement for each of the 11 tests appeared to be good or very good (0.61-1.00). However, when data for hands or feet with normal strength or complete paralysis were excluded from the analysis, the reliability of the remaining mid-range scale was not acceptable (kappa 0.55-0.88, direct agreement range 11-41%). While the reliability of this scale could possibly be improved by special training, we feel that, for the evaluation of nerve function for leprosy patients with (suspected) nerve function loss, the extended 9-point VMT scale should only be used when direct intra- or intertester agreement is more than 80%.

Ocular impairments in an impairment survey of leprosy-affected persons in Nepal.

An impairment survey was carried out in Nepal. The study subjects (n = 318) were a mixture of out-patients and patients admitted less than one month before the survey. Of the subjects, 101 were attending the hospital out-patients clinic or were admitted and the rest were examined in the field. The patients studied included those on MDT and care-after-cure cases. Ocular impairments were found in 25% of these cases. The most common ocular impairment was poor vision followed by lagophthalmos and insensitive cornea.

Progress of impairment scores following commencement of chemotherapy in multibacillary leprosy patients.

STUDY AIM: To investigate the progress of impairment over time in multibacillary (MB) leprosy patients. STUDY DESIGN: Retrospective cohort study. STUDY POPULATION: One-thousand-eighty-two MB patients newly registered in nine field clinics in the Western Region of Nepal between 1980 and 1993. METHODS: Data on impairment at diagnosis and at yearly intervals afterward were collected from patient records of MB patients already released from multidrug therapy (MDT). The World Health Organization (WHO) 1988 "disability" grading scale (0-2, for both eyes, hands and feet--six sites) was used as a measure of impairment. For the analysis we summed the WHO grading for the six sites into an eyes-hands-feet (EHF) sum score (minimum 0, maximum 12). The EHF score at 2 years of follow up was used to compute the main outcome measures: impairment at 2 years, yes or no, and deterioration of impairment compared with diagnosis. The combined effect of age, sex, classification and impairment status at diagnosis on the outcome was examined with logistic regression. RESULTS: At diagnosis, 55.8% of the patients had some impairment. This proportion decreased over 2 years to 43.9%. Among patients without initial impairment, 31/310 (10%) developed impairment during the study period. This was 81/396 (20.5%) among patients with impairment at diagnosis. The adjusted odds ratio (OR) for developing impairment was 1.87 [95% confidence interval (CI) 1.06-3.32] for patients with initial sensory impairment (WHO grade 1). and 1.98 (95% CI 1.15-3.4) for those with initial visible deformity (WHO grade 2). Among patients with impairment at diagnosis, 195/396 (49.2%) had improved after 2 years. CONCLUSIONS: The proportion of patients with impairment after 2 years of antileprosy treatment was 12% less than at diagnosis. Among patients without initial impairment, 10% had developed some impairment after 2 years. The risk of developing impairment was almost double for those with sensory impairment or visible deformity at diagnosis. For purposes of monitoring, evaluation and planning, both the proportion of patients with sensory impairment (WHO grade 1) and the proportion with visible deformity (WHO grade 2) should be reported at diagnosis and at release from treatment.

Functional sensibility of the hand in leprosy patients.

The aims of this cross-sectional comparative study was to compare the results of Semmes-Weinstein monofilament testing (SWM) and moving 2-point discrimination (M2PD) with four tests of functional sensibility: recognition of objects, discrimination of size and texture and detection of dots. Ninety-eight leprosy in- and outpatients at Green Pastures Hospital in Pokhara, Nepal were tested with each of the above tests and the results were compared to see how well they agreed. Using the tests of functional sensibility as reference points, we examined the validity of the SWM and M2PD as predictors of functional sensibility. There was definite, but only moderate correlation between thresholds of monofilaments and M2PD and functional sensibility of the hand. A normal result with the SWM and/or M2PD had a good predictive value for normal functional sensibility. Sensitivity was reasonable against recognition of objects and discrimination of textures as reference tests (80-90% and 88-93%), but poor against discrimination of size and detection of dots (50-75% and 43-65%). Specificity was high for most combinations of SWM or M2PD with any of the tests of functional sensibility (85-99%). Above a monofilament threshold of 2 g, the predictive value of an abnormal test was 100% for dot detection and 83-92% for textural discrimination. This indicates that impairment of touch sensibility at this level correlates well with loss of dot detection and textural discrimination in patients with leprous neuropathy. For M2PD the pattern was very similar. Above a threshold of 5 mm, 95-100% of affected hands had loss of dot detection and 73-80% had loss of textural discrimination. Monofilament testing and M2PD did not seem suitable as proxy measures of functional sensibility of the hand in leprosy patients. However, a normal threshold with monofilaments and/or M2PD had a good predictive value for normal functional sensibility. Above a monofilament threshold of 2 g and/or a M2PD threshold of 5 mm, textural discrimination was abnormal in most hands.