Exploring clustering of leprosy in the Comoros and Madagascar: A geospatial analysis.

OBJECTIVES: To identify patterns of spatial clustering of leprosy. DESIGN: We performed a baseline survey for a trial on post-exposure prophylaxis for leprosy in Comoros and Madagascar. We screened 64 villages, door-to-door, and recorded results of screening, demographic data and geographic coordinates. To identify clusters, we fitted a purely spatial Poisson model using Kulldorff's spatial scan statistic. We used a regular Poisson model to assess the risk of contracting leprosy at the individual level as a function of distance to the nearest known leprosy patient. RESULTS: We identified 455 leprosy patients; 200 (44.0%) belonged to 2735 households included in a cluster. Thirty-eight percent of leprosy patients versus 10% of the total population live ≤25 m from another leprosy patient. Risk ratios for being diagnosed with leprosy were 7.3, 2.4, 1.8, 1.4 and 1.7, for those at the same household, at 1-<25 m, 25-<50 m, 50-<75 m and 75-<100 m as/from a leprosy patient, respectively, compared to those living at ≥100 m. CONCLUSIONS: We documented significant clustering of leprosy beyond household level, although 56% of cases were not part of a cluster. Control measures need to be extended beyond the household, and social networks should be further explored.

Protocol, rationale and design of PEOPLE (Post ExpOsure Prophylaxis for LEprosy in the Comoros and Madagascar): a cluster randomized trial on effectiveness of different modalities of implementation of post-exposure prophylaxis of leprosy contacts.

BACKGROUND: Leprosy is an ancient infectious disease with a global annual incidence that has plateaued above 200,000 new cases since over a decade. New strategies are required to overcome this stalemate. Post-exposure prophylaxis (PEP) with a single dose of Rifampicin (SDR) has conditionally been recommended by the World Health Organization (WHO), based on a randomized-controlled-trial in Bangladesh. More evidence is required. The Post ExpOsure Prophylaxis for Leprosy (PEOPLE) trial will assess effectiveness of different modalities of PEP on the Comoros and Madagascar. METHODS: PEOPLE is a cluster-randomized trial with villages selected on previous leprosy-incidence and randomly allocated to four arms. Four annual door-to-door surveys will be performed in all arms. All consenting permanent residents will be screened for leprosy. Leprosy patients will be treated according to international guidelines and eligible contacts will be provided with SDR-PEP. Arm-1 is the comparator in which no PEP will be provided. In arms 2, 3 and 4, SDR-PEP will be provided at double the regular dose (20 mg/kg) to eligible contacts aged two years and above. In arm 2 all household-members of incident leprosy patients are eligible. In arm 3 not only household-members but also neighbourhood contacts living within 100-m of an incident case are eligible. In arm 4 such neighbourhood contacts are only eligible if they test positive to anti-PGL-I, a serological marker. Incidence rate ratios calculated between the comparator arm 1 and each of the intervention arms will constitute the primary outcome. DISCUSSION: Different trials on PEP have yielded varying results. The pivotal COLEP trial in Bangladesh showed a 57% reduction in incidence over a two-year period post-intervention without any rebound in the following years. A study in a high-incidence setting in Indonesia showed no effect of PEP provided to close contacts but a major effect of PEP provided as a blanket measure to an entire island population. High background incidence could be the reason of the lack of effect of PEP provided to individual contacts. The PEOPLE trial will assess effectiveness of PEP in a high incidence setting and will compare three different approaches, to identify who benefits most from PEP. TRIAL REGISTRATION: Clinicaltrials.Gov. NCT03662022. Initial Protocol Version 1.2, 27-Aug-2018.

[Neurologic diseases in a rural tropical area: experience at a primary health care center in the Boeny region of Madagascar]. / Pathologies neurologiques en milieu tropical et rural : expérience malgache d'un centre de santé primaire de la région de Boeny.

There is, to our knowledge, no study reporting the demand for health care related to neurological diseases in rural tropical areas of developing countries. Neurology is nonetheless more or less closely related to the priority health issues in these countries. Over a 6-week period, 626 patients were seen at the primary health center in the town of Madirovalo, Madagascar. Neurological disorders accounted for 11.1% of the consultations. The neurological disorders most frequently leading to consultations were headaches (42.7%), with primary headaches accounting for 16%; next came leprosy neuropathy (14.7%), with a worrisome total of 8 new cases; other peripheral neuropathies (13.3%), and epilepsy (12%). The relatively low share of the latter seems likely related to families' frequent use of traditional healers rather than Western medicine. Neurological diseases appears to represent a significant part of the health-care demand of people living in rural tropical areas of developing countries, and specific support in this specialization is essential.

[Survey of the quality of leprosy diagnosis in Madagascar]. / Enquête sur la qualité du diagnostic de lèpre à Madagascar.

BACKGROUND: By 2005, Madagascar had not achieved its goal of eliminating leprosy. During reexamination of leprosy patients, rates of diagnostic error ranged from 4.5 to 62%, casting doubt on the reported prevalence of leprosy. We therefore decided to carry out a survey of the quality of leprosy diagnosis. PATIENTS AND METHODS: The survey consisted in reexamination of a sample of 102 new cases of leprosy (treated for less than three months). The sample was obtained from clusters of six patients, randomly drawn from the 111 districts in the country's six provinces. Two reexamination teams visited the target districts. Each team included at least three medical doctors: a doctor from the National Program, a WHO consultant and a dermatologist from partner NGOs in the program. RESULTS: The mean false-positive rate was 27.5%, ranging from 5.6 to 44.4% in the different provinces. The quality of leprosy diagnosis was found to be very poor, particularly in districts with a marked decrease in annual detection of leprosy cases. CONCLUSION: The high rate of false-positives during this survey could be due to the incompetence of peripheral health workers. This incompetence could be partly attributed to the decrease in leprosy detection, resulting in reduced familiarity of these health staff with leprosy diagnosis. Recommendations were made to the country concerning review of the leprosy case detection network and improvement of the quality of leprosy diagnosis in the field. Health workers involved in leprosy detection must have basic dermatological knowledge.

[Leprosy surgery in a bush hospital in Africa: experience in Madagascar]. / La chirurgie de la lèpre dans un hôpital de brousse en Afrique: expérience à Madagascar.

We report our experience of leprosy surgery in terms of feasibility and efficacy in a small hospital of bush in Madagascar during the period of September 1989 to January 1993. Operations of neurolysis, corrections of claw hands by the techniques of Lasso-Zancolli or Van Droogenbroeck, arthrodesis, resections and amputations have been performed. Our results suggest that at least a part of these surgical procedures may be performed by a non specialized medical team, taught on the premises. Thus, the cost of treatment will be low and accessible to more leprosy patients.

[Leprosy surgery: retrospective study in Madagascar]. / La chirurgie de la lèpre: étude rétrospective à Madagascar.

Leprosy is endemic in Madagascar and the diagnosis of leprosy is still done lately. Thus, many patients suffer from multiple and/or severe disabilities. Since a long time, many leprologists argue that surgery is necessary and useful in the treatment of these disabilities. We report the results of a retrospective study done in 25 patients reevaluated 2 to 7 years after surgery. Of these patients: 17 patients (68%) have success, 7 patients (28%) have a partial improvement and only 1 case (4%) had no benefit. These results are encouraging and suggest that surgery must be proposed more often to treat in leprosy disabilities.

[Leprosy situation in the southeastern region of Madagascar from 1996 to 1998]. / Situation de la lèpre dans une région du Sud-Est de Madagascar de 1996 à 1998.

Leprosy is endemic in Madagascar. The authors report the results of an epidemiologic study performed between 1996 and 1998 in Farafanguna, localized in the South-Eastern of the country. During this period, 217 new cases have been diagnosed. Of the 130 cases included in the study, 69.23% were children aged lower than 15 years and 76.91% suffered from a multibacillary form. More than 50% of the cases belonged to a large family (6 persons or more) and at least one family case was found in more than 60% of cases. These results enhance the severity of the disease in the country and show the presence of multiple risk factors (promiscuity, family cases and multibacillary forms).

[Squamous cell carcinoma arising from chromomycosis. Report of two cases]. / Carcinome épidermoïde développé sur des lésions de chromomycose. A propos de deux observations.

Madagascar is the principal area of endemic chromomycosis in the world with 1 400 cases registered from 1955 to 1996. Malignant transformation is rare and only 12 cases have been reported. We describe herein two new cases of squamous carcinoma arising from chronic lesions of chromomycosis. These carcinomas which develop slowly and are non invasive, are similar to those arising from burns, tropical phagedenic ulcers and chronic leprosy ulcers. Epidemiological aspects, histopathology and treatment are described.

[Role of catholic centers in the control of tuberculosis]. / Place des centres catholiques dans la lutte contre la tuberculose.

This study briefly reports the results of a survey conducted by the National Tuberculosis Control Programme (NTCP) to asses the Catholic Centres and particularly the leper colonies activities of tuberculosis control. Among the 34 Catholic Centres taking care of the lepers, 11 take part in the NTCP. Within less than 3 years, most of these centres have taken charge of twice more tuberculous patients: the number of cases increased from 540 to 1045. Leprosy prevalence is constantly decreasing, thus multibacillary leprosy cases declared by these centres decreased of 28% from 1992, to 1994. Centres which did not begin conversion would feel this necessity soon. Germs responsible for leprosy and for tuberculosis are "first cousins". Technical and operational approaches for the control of both affections are very much alike. Those considerations logically induce to propose the conversion of antileprosy centres for tuberculosis control. Other arguments are partially exposed in this work. The Central Division knows the existence of 28 Catholic Centres throughout the country, taking charge of tuberculous patients. In 1994, they put more than 1600 patients under treatment, thus 15% of the tubercular in Madagascar. Those Catholic Centres implementing tuberculosis control programme ought set up a "federation" as a privileged interlocutor for the NTCP and for the financial backers when allowing support. Responsibles of the Programme expect to convince Centres of the necessity of conversion and of the interest of tuberculosis control.

[Cutaneous neoplasms during leprosy: 2 case reports]. / Néoplasie cutanée au cours de la lèpre: a propos de deux cas.

The authors report on two cases of dermal neoplasia in foot trophic disorders observed in leprous subjects. The report includes the description of the clinic and histologic data as well as the surgical technique used; finally, it underlines the importance of a precocious diagnostic so as to obtain a good therapeutic result.

[Contribution to investigation of leprosy ocular disease in madagascar (author's transl)]. / Contribution à l'étude des manifestations oculaires de la lèpre à Madagascar.

250 leprous from National Leprosery of Manankavaly (distant of 30 km from Tananarive) were examined. Among them, 31 patients present ocular disease which occur with that of leper isn't accurately known. Conjuntival reactions as prickling, watering of the eyes with inability to assimilate wind light constitute initial symptoms. Cataract is exceptional (only one case); but we point out; first the superiority of "uveal tractus" disease with 32% of rate; then, the frequency of deep of interstitial keratitis (35%). These lesions are and seem to evolute freely in spite of Iper therapeutic and its stabilisation. So cured of leprosy patients two sided may come back because of the increasing of their ocular sickness. Due to lesion of anterior segment, eye fundus is difficult to analyse, but nervous disease may exist on optical papilla, considering the disproportion between the degrees of uveitis and sight alteration. Researching hansen Bacillus and other germs responsible of eye lesions, we sampled secretions of conjonctiva. We haven't anatome-pathological results because of failure of enucleated eye-ball. Leprosy ocular disease invariably end in blindness by eye-ball atrophy.

[What was the fate of patients with leprosy during the plague pandemia in the middle ages (1348-1350)]. / Quel fut le sort des lépreux au cours de la pandémie pesteuse du moyen age (1348-1350)

The author thinks that, if lepra has suddenly decreased in Europe from the 14th century, it is because the most severe cases, i.e. the most contagious ones, disappeared during the hecatombs caused between 1348 and 1350 by the "Black Death", the black plague, which took most often the pulmonary form. The author disproves the opinion of those who think that lepers died from plague. He thinks that lepers' death was secondary to that of the monks who, at this time, cared for these outcases, and thanks to their self-sacrifice permitted these lepers' survival. The monks were more exposed to contagion; obliged by their vocation and by pope's command to help the dyings and to give them sacraments, they were obliged to leave lepers to their fate. Like domestic animals, the latter died of hunger probably, any corpse or carcass being considered as plague victims. Supporting this opinion, the author reports his observations at Madagascar, where no leper of the leper-houses of Madascar center, a plague focus still to-day but very active between 1922 and 1936, contracted plague. On the other hand, experiments with "leprous" rats (Stefansky bacillus) showed a significant resistance of these animals to an experimental plague infection.