The effect of conditional cash transfers on the control of neglected tropical disease: a systematic review.

BACKGROUND: Neglected tropical diseases (NTDs) are diseases of poverty and affect 1·5 billion people globally. Conditional cash transfer (CCTs) programmes alleviate poverty in many countries, potentially contributing to improved NTD outcomes. This systematic review examines the relationship between CCTs and screening, incidence, or treatment outcomes of NTDs. METHODS: In this systematic review we searched MEDLINE, Embase, Lilacs, EconLit, Global Health, and grey literature websites on Sept 17, 2020, with no date or language restrictions. Controlled quantitative studies including randomised controlled trials (RCTs) and observational studies evaluating CCT interventions in low-income and middle-income countries were included. Any outcome measures related to WHO's 20 diseases classified as NTDs were included. Studies from high-income countries were excluded. Two authors (AA and TH) extracted data from published studies and appraised risk of biases using the Risk of Bias in Non-Randomised Studies of Interventions and Risk of Bias 2 tools. Results were analysed narratively. This study is registered with PROSPERO, CRD42020202480. FINDINGS: From the search, 5165 records were identified; of these, 11 studies were eligible for inclusion covering four CCTs in Brazil, the Philippines, Mexico, and Zambia. Most studies were either RCTs or quasi-experimental studies and ten were assessed to be of moderate quality. Seven studies reported improved NTD outcomes associated with CCTs, in particular, reduced incidence of leprosy and increased uptake of deworming treatments. There was some evidence of greater benefit of CCTS in lower socioeconomic groups but subgroup analysis was scarce. Methodological weaknesses include self-reported outcomes, missing data, improper randomisation, and differences between CCT and comparator populations in observational studies. The available evidence is currently limited, covering a small proportion of CCTs and NTDs. INTERPRETATION: CCTs can be associated with improved NTD outcomes, and could be driven by both improvements in living standards from cash benefits and direct health effects from conditionalities related to health-care use. This evidence adds to the knowledge of health-improving effects from CCTs in poor and vulnerable populations. FUNDING: None.

Economic evaluation of patient costs associated with tuberculosis diagnosis and care in Solomon Islands.

BACKGROUND: Tuberculosis (TB) care can be costly for patients and their families. The End TB Strategy includes a target that zero TB affected households should experience catastrophic costs associated with TB care. Costs are catastrophic when a patient spends 20% or more of their annual household income on their TB diagnosis and care. In Solomon Islands the costs of TB care are unknown. The aim of this study was to determine the costs of TB diagnosis and care, the types of costs and the proportion of patients with catastrophic costs. METHODS: This was a nationally representative cross-sectional survey of TB patients carried out between 2017 and 2019. Patients were recruited from health care facilities, from all ten provinces in Solomon Islands. During an interview they were asked about the costs of TB diagnosis and care. These data were analysed using descriptive statistics to describe the costs overall and the proportions of different types of costs. The proportion of patients with catastrophic costs was calculated and a multivariate logistic regression was undertaken to determine factors associated with catastrophic costs. RESULTS: One hundred and eighty-three TB patients participated in the survey. They spent a mean of 716 USD (inter quartile range: 348-1217 USD) on their TB diagnosis and care. Overall, 62.1% of costs were attributable to non-medical costs, while income loss and medical costs comprised 28.5 and 9.4%, respectively. Overall, 19.7% (n = 36) of patients used savings, borrowed money, or sold assets as a financial coping mechanism. Three patients (1.6%) had health insurance. A total of 92.3% (95% CI: 88.5-96.2) experienced catastrophic costs, using the output approach. Being in the first, second or third poorest wealth quintile was significantly associated with catastrophic costs (adjusted odds ratio: 67.3, 95% CI: 15.86-489.74%, p <  0.001). CONCLUSION: The costs of TB care are catastrophic for almost all patients in Solomon Islands. The provision of TB specific social and financial protection measures from the National TB and Leprosy Programme may be needed in the short term to ameliorate these costs. In the longer term, advancement of universal health coverage and other social and financial protection measures should be pursued.

Dietary diversity and poverty as risk factors for leprosy in Indonesia: A case-control study.

BACKGROUND: Poverty has long been considered a risk factor for leprosy and is related to nutritional deficiencies. In this study, we aim to investigate the association between poverty-related diet and nutrition with leprosy. METHODOLOGY/PRINCIPAL FINDINGS: In rural leprosy-endemic areas in Indonesia, we conducted a household-based case-control study using two controls for each case patient (100 recently diagnosed leprosy patients and 200 controls), matched for age and gender. All participants were interviewed to collect information on their demographics, socioeconomic situation, health, and diet. Body mass index, dietary diversity score, as well as anemia and iron micronutrient profiles were also obtained. By means of univariate, block-wise multivariate, and integrated logistic regression analyses, we calculated odds ratios between the variables and the occurrence of leprosy. Unstable income (odds ratio [OR], 5.67; 95% confidence interval [CI], 2.54-12.64; p = 0.000), anemia (OR, 4.01; 95% CI, 2.10-7.64; p = 0.000), and higher household food insecurity (OR, 1.13; 95% CI, 1.06-1.21; p = 0.000) are significantly associated with an increased risk of having leprosy. Meanwhile, higher education (OR, 0.34; 95% CI, 0.15-0.77; p = 0.009) and land ownership (OR, 0.39; 95% CI, 0.18-0.86; p = 0.019) have significant protective associations against leprosy. Although lower dietary diversity, lack of food stock, food shortage, low serum iron, and high ferritin were found more commonly in those with leprosy, the occurrence of leprosy was not significantly associated with iron deficiency (OR, 1.06; 95% CI, 0.10-11.37; p = 0.963). CONCLUSIONS/SIGNIFICANCE: Food poverty is an important risk factor for leprosy susceptibility, yet the mechanisms underlying this association other than nutrient deficiencies still need to be identified. With a stable incidence rate of leprosy despite the implementation of chemoprophylaxis and multidrug therapy, improving dietary diversity through food-based approaches should be initiated and directed toward high-prevalence villages. The possible underlying factors that link poverty to leprosy other than nutrient deficiencies also need to be identified.

Is disability in leprosy still a burden? A cross-sectional study in a rural block in Tamil Nadu, India.

Background: Leprosy, a disease caused by Mycobacterium leprae, is an important cause of preventable disability. Methods: The present cross-sectional study was undertaken among leprosy-affected persons in a rural block in Kanchipuram District, Tamil Nadu, India in the year 2013. The sample included treatment completed leprosy affected persons ≥18 y of age. Persons with difficulty in cognition and those who were not willing to participate in the study were excluded. Subjects were also graded for any deformities of the body using World Health Organization (WHO) disability grading. Results: The present study, carried out among 171 people affected with leprosy in a rural block, showed the lifetime prevalence of disability was 88.3% (95% confidence interval 83.4 to 93.1). The mean age of the study participants was 61.58±12.31 y with almost equal distribution of males (49.7%) and females (50.3%). WHO disability grading showed that 147 (86%) of the subjects were grade 2 (visible deformity) while only 4 (2.3%) were grade 1. It was found that education, occupation, income and duration since diagnosis had statistical significance with disability. Conclusions: Disability was observed more in males and the most common type of deformity was hand and foot deformity. Further studies are needed to assess those patients who completed treatment and recommends periodic neurological assessment of those in treatment.

Guidelines for management of rheumatic diseases in developing countries from basics to real-world situation: relevance, need, and processes for development.

Guidelines or recommendations help to provide uniform standards in medical practice. The development of guidelines requires adherence to pre-defined norms prescribed by different international organizations such as the European League against Rheumatism (EULAR). We searched Pubmed and LILACS to identify published papers in five major rheumatic diseases (rheumatoid arthritis, systemic lupus erythematosus, spondyloarthropathies, osteoarthritis, and scleroderma) from different countries based on their economic prosperity and could find a lack of published literature from most economically weaker regions. Similarly, published guidelines in these rheumatic diseases were sparse from Asia and Africa, which are economically developed to a lesser extent than other regions of the world. Considering differing economic realities driving patient care in different regions of the world, unique challenges in certain geographic areas such as musculoskeletal manifestations of infectious diseases like leprosy and tuberculosis, as well as distinct risk of malignancies and other comorbid conditions, National Rheumatology societies should work towards developing more guidelines for rheumatic diseases from regions such as Asia and Africa, while following strictly the prescribed norms for the same. With a paucity of guidelines for such regions currently, an alternative (although less preferable) suggestion would be that major international societies, whose guidelines are widely read and followed the world over, should consider inputs from experts from diverse regions of the world while developing these guidelines.

Between-Country Inequalities in the Neglected Tropical Disease Burden in 1990 and 2010, with Projections for 2020.

BACKGROUND: The World Health Organization (WHO) has set ambitious time-bound targets for the control and elimination of neglected tropical diseases (NTDs). Investing in NTDs is not only seen as good value for money, but is also advocated as a pro-poor policy since it would improve population health in the poorest populations. We studied the extent to which the disease burden from nine NTDs (lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths, trachoma, Chagas disease, human African trypanosomiasis, leprosy, visceral leishmaniasis) was concentrated in the poorest countries in 1990 and 2010, and how this would change by 2020 in case the WHO targets are met. PRINCIPAL FINDINGS: Our analysis was based on 1990 and 2010 data from the Global Burden of Disease (GBD) 2010 study and on projections of the 2020 burden. Low and lower-middle income countries together accounted for 69% and 81% of the global burden in 1990 and 2010 respectively. Only the soil-transmitted helminths and Chagas disease caused a considerable burden in upper-middle income countries. The global burden from these NTDs declined by 27% between 1990 and 2010, but reduction largely came to the benefit of upper-middle income countries. Achieving the WHO targets would lead to a further 55% reduction in the global burden between 2010 and 2020 in each country income group, and 81% of the global reduction would occur in low and lower-middle income countries. CONCLUSIONS: The GBD 2010 data show the burden of the nine selected NTDs in DALYs is strongly concentrated in low and lower-middle income countries, which implies that the beneficial impact of NTD control eventually also largely comes to the benefit of these same countries. While the nine NTDs became increasingly concentrated in developing countries in the 1990-2010 period, this trend would be rectified if the WHO targets were met, supporting the pro-poor designation.

Household costs of leprosy reactions (ENL) in rural India.

BACKGROUND: Erythema nodosum leprosum (ENL) is a common immune-mediated complication of lepromatous (LL) and borderline lepromatous (BL) leprosy. Most patients experience chronic or multiple acute ENL over many years during an economically active period of their lives. Understanding the economic burden of ENL is essential to provide effective patient support, yet this area has not been investigated. METHODS: Ninety-one patients with LL or BL leprosy attending a leprosy hospital in Purulia district of West Bengal, India, were interviewed using a structured questionnaire. Cases (n = 53) were identified as those who had one or more episodes of ENL within the last 3 years. Controls (n = 38) had LL or BL leprosy but no history of ENL. Data were collected on household income, direct and indirect costs, and coping strategies. FINDINGS: The total household cost was Rs 1543 per month or 27.9% (IQR 13.2-52.6) of monthly household income for cases, and Rs 237 per month or 4.9% (IQR 1.7-13.4) of monthly household income for controls. Indirect costs accounted for 65% of total household costs for cases. Direct costs accounted for the remaining 35% of household costs, and resulted almost entirely from treatment-seeking in the private sector. Total household costs exceeded 40% of household income for 37.7% of cases (n = 20) and 2.6% of controls (n = 1) [1 USD = 59 INR]. INTERPRETATION: Households affected by ENL face significant economic burden and are at risk of being pushed further into poverty. Health policy should acknowledge the importance of private sector provision and the significant contribution to total household costs of lost productivity (indirect cost). Further work is needed to explore this area and identify solutions.

Responding to the challenge of leprosy-related disability and ultra-poverty.

INTRODUCTION: The Millennium Development Goals have provided much needed attention to extreme poverty reduction. However, people with disabilities are disproportionately affected by poverty and in some countries, even the goal of US$1 per day is far out of reach. For people with leprosy-related disability living in ultra-poverty (on less than 50 cents a day), many mainstream poverty reduction strategies are inaccessible and inappropriate. METHOD: A project in north-west Bangladesh developed a more contextually meaningful definition of ultra-poverty according to nutrition energy intake. A total of 2372 people with leprosy-related disability were surveyed. Of those, 1285 individuals fell below the ultra-poverty line. Individualised interventions were implemented over an extended period of time, comprised of targeted practical assistance, enhancing community links, advocacy for entitlements, and further linking with other initiatives. RESULTS: Follow-up data available for 856 individuals showed an average increase in per capita income of 83%. Personal contribution to the family income increased by 65%. There was a 51% increase in families having access to a latrine. Finally families reported eating 30% more meals per day, up from an average of two meals per day. CONCLUSIONS: The initiative sought to address poverty in a wide variety of ways, using minimal inputs. Over several years, the results indicate a significant change in the economic situation of individuals with leprosy related disabilities. Other organisations are encouraged to duplicate the intervention and share their results.

Socio-economic and environmental effects influencing the development of leprosy in Bahia, north-eastern Brazil.

OBJECTIVES: To investigate spatial clusters and possible associations between relative risks of leprosy with socio-economic and environmental factors, taking into account diagnosed cases in children under 15 years old. METHODS: An ecological study was conceived using data aggregated by municipality to identify possible spatial clusters of leprosy from 2005 to 2011. Relative risks were calculated accounting for the respective covariate gender. The second stage of the analysis consisted of verifying possible associations between the relative risks of leprosy as a dependent variable, and socio-economic and environmental variables as independent. This was performed using a multivariate regression analysis according to a previously defined conceptual framework. RESULTS: Overall rates have decreased from 0.88/10 000 in 2005 to 0.52 in 2011. Spatial scan statistics identified 4 high-risk and 6 low-risk clusters. In the regression model, after allowing for spatial dependence, relative risks were associated with higher percentage of water bodies, higher Gini index, higher percentage of urban population, larger average number of dwellers by permanent residence and smaller percentage of residents born in Bahia. CONCLUSIONS: Although relative risks of leprosy in Bahia have been decreasing, they remain very high. The association between relative risks of leprosy and water bodies in the proposed geographic scale indicates that hypothesis linking M. leprae and humid environments cannot be discarded. Socio-economic conditions such as inequality, a greater number of dwellers by residence and migration are derived from the urbanisation process carried out in this State. Precarious settlements and poor living conditions in the cities would favour the continuity of leprosy transmission.

Limitations in activities of people affected by leprosy after completing multidrug therapy: application of the SALSA scale.

OBJECTIVES: To identify people affected by leprosy with impairments after completing multidrug therapy for leprosy, and to assess their limitations in conducting daily activities by applying the Screening of Activity Limitation and Safety Awareness (SALSA) scale. METHODS: A cross-sectional study was performed of all residents of a medium-sized city who were treated for leprosy from 1998 to 2006. A specific questionnaire was applied to obtain general and clinical data and the SALSA scale was used to assess limitations in activities. Impairments were assessed using the 'World Health Organization leprosy disability grading system' (WHO-DG). FINDINGS: Of the 335 people affected by leprosy treated in the period, 223 (62.1%) were located and interviewed. A total of 51.6% were female with a mean age of 54 years (SD +/- 15.72) and 67.9% had up to 6 years formal education. The borderline form predominated among interviewees (39.9%) and 54.3% suffer from associated diseases with hypertension (29.1%) and diabetes (10.3%) being the most common. Pain was reported by 54.7% of interviewees. By multiple logistic regression analysis, associations were found between limitations in activities and being female (P < 0.025), family income < or = 3 minimum wages (P-value < 0.003), reports of major lesions (P-value < 0.004), pain (P-value < 0.001), associated diseases (P-value < 0.023) and the WHO-DG (P-value < 0.001). Disabilities, as identified using the WHO-DG, were less common (32%) than limitations in activities as evaluated by the SALSA scale (57.8%). CONCLUSION: Limitations in activities proved to be common in people affected by leprosy and were associated with low income, being female, reported major lesions, disability, disease and pain.

Social participation of people affected by leprosy after discontinuation of multidrug therapy.

OBJECTIVES: To evaluate social participation of individuals completing treatment for leprosy and to describe the relationship with physical sequelae and sociodemographic characteristics. DESIGN: A cross-sectional, descriptive study was performed involving all leprosy affected people who were treated between 1998 and 2006 in São José do Rio Preto, Brazil. General and clinical data were collected and the subjects were assessed using the degree of physical disability of the WHO (DPD-WHO), the Eye-hand-foot (EHF) score, and the participation scale (PS), which measures social participation of individuals with stigmatising problems. RESULTS: Of the 335 people treated in the period, 223 (66.6%) were interviewed. Of these, 51.6% were women, the mean age was 54 years (+/- 15.7 years), 66.4% had up to 6 years of formal education, 42.6% worked and 26.9% were retired. There was a predominance of dimorphous (borderline) leprosy (39.9%). Participants' physical and mental health was considered good in the month preceding the interview in 50.2% and 59.2%, respectively. Disabilities according to the DPD-WHO and EHF scores affected 32% of the participants and restrictions in social participation occurred in 35.4%. Multivariate analysis demonstrated a significant association between restrictions in social participation and family income of less than three minimum salaries (US$ 160.50), associated diseases, hospitalisation within the previous year and physical disability. CONCLUSION: The prevalence of restrictions in social participation is high, even after completing treatment for leprosy. Physical disability, associated diseases, recent hospitalisation and low family incomes influence the social participation of these individuals.

Social inequality, urban growth and leprosy in Manaus: a spatial approach.

OBJECTIVE: To analyze the epidemiology of leprosy according to spatial distribution and living conditions of the population. METHODS: Ecological study based on the spatial distribution of leprosy in the municipality of Manaus, Northern Brazil, from 1998 to 2004. The 4,104 cases identified in the Sistema de Informações de Agravos de Notificação (Sinan -National Notification System) were georeferenced according to the addresses in the 1,536 urban census tracts through four different sources: postal service (73.7% of addresses found), Property Registration Program (7.3%), Family Health Program (2.1%), and Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics) data sheet (1.5%). Calculation of detection coefficient was performed based on the 2001 population. Local empirical Bayesian method was used for the spatial distribution analysis, in order to estimate leprosy risk, making rate variation shorter when they were calculated for small areas. Logistic regression was employed to analyze the association between geographical distribution and risk factors. The incidence of cases in children under 15 (severity indicator) and Social Need Index built from variables of the 2000 census were adopted as explicative variables. RESULTS: The mean coefficient of detection was hyperendemic in 34.0% of the census tracts, and very high in 26.7%. Odds ratio was obtained for explicative variables and proved to be significant. Low-income and incidence in children under 15 were combined to identify priority areas for intervention. CONCLUSIONS: Spatial analysis of leprosy showed that the distribution of the disease is heterogeneous and is more strongly present in regions inhabited by more vulnerable groups.

The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination.

The neglected tropical diseases (NTDs) represent some of the most common infections of the poorest people living in the Latin American and Caribbean region (LAC). Because they primarily afflict the disenfranchised poor as well as selected indigenous populations and people of African descent, the NTDs in LAC are largely forgotten diseases even though their collective disease burden may exceed better known conditions such as of HIV/AIDS, tuberculosis, or malaria. Based on their prevalence and healthy life years lost from disability, hookworm infection, other soil-transmitted helminth infections, and Chagas disease are the most important NTDs in LAC, followed by dengue, schistosomiasis, leishmaniasis, trachoma, leprosy, and lymphatic filariasis. On the other hand, for some important NTDs, such as leptospirosis and cysticercosis, complete disease burden estimates are not available. The NTDs in LAC geographically concentrate in 11 different sub-regions, each with a distinctive human and environmental ecology. In the coming years, schistosomiasis could be eliminated in the Caribbean and transmission of lymphatic filariasis and onchocerciasis could be eliminated in Latin America. However, the highest disease burden NTDs, such as Chagas disease, soil-transmitted helminth infections, and hookworm and schistosomiasis co-infections, may first require scale-up of existing resources or the development of new control tools in order to achieve control or elimination. Ultimately, the roadmap for the control and elimination of the more widespread NTDs will require an inter-sectoral approach that bridges public health, social services, and environmental interventions.

Funding for self-employment of people with disabilities. Grants, loans, revolving funds or linkage with microfinance programmes.

In 2005, Handicap International commissioned a study on the practices of funding for self-employment activities of people with disabilities (PWD), with a special focus on access to microfinance. The overall goal of the study was to produce a framework document highlighting good practices, strategies, tools and operational methods that guarantee the efficiency and sustainability of self-employment projects for PWDs. The first phase of the study consisted of a literature review and a worldwide survey. Through this first phase the research team identified the most innovative programmes for further analysis through field visits. In the second phase field visits were conducted in Afghanistan, Bangladesh, Ethiopia, India, Kenya, Nicaragua and Uganda, while regional workshops were organised in Dhaka and Nairobi. Phase three involved consolidation and analysis of the information and finally drafting of the framework document. This paper summarises the findings and good practices as presented in the framework document, based on the results of the literature review, the survey and the field research. It is not a scientific paper, i.e. it doesn't contain a discussion of the literature reviewed or systematic reference to sources, the same as the document on which it is based, as it is primarily meant for 'practitioners'. A main finding of the study was that there is no single 'best solution' to funding of self employment activities. While inclusion of PWDs in existing microfinance institutions (MFIs) is the preferred strategy, guaranteeing efficiency, sustainability and future access to funding for the target group, it was found that in reality many PWDs do not have access to microfinance programmes. This can be explained by stigmatisation of PWDs by staff of MFIs, who do not believe in their income earning and repayment capacity, and self-exclusion by PWDs. To fight against it projects have been set-up linking MFIs with programmes for PWDs, focusing on better information exchange between both parties respectively on disability for MFIs and the characteristics of microfinance for programmes for PWDs. Other programmes experiment with special credit lines or guarantee funds, placed at the disposal of MFls and earmarked for loan disbursement for PWDs, to facilitate their inclusion. Another reason for non-inclusion is the vulnerability of many PWDs. Many of them have no prior business experience, while many MFIs only provide loans to clients with an existing business. Vocational and/or business training and raising of their self-confidence, to be assured by a programme for PWDs, is often required prior to setting-up of a self-employment activity and taking a loan. If not prepared to run a 'business' successfully, taking a loan will present a too great a risk for themselves, getting indebted, and for the MFI. 'Start-up' grants for business-starters and revolving funds managed by PWD programmes, are other approaches practised by PWD programmes, of which the pros and cons are discussed in the study. A major weakness of many MFIs is that they do not reach the most vulnerable clients, including many of the PWDs, and their weak presence in rural areas especially in Africa. MFls have to look for innovative approaches to deepen their outreach. The self-help group approach in India, starting with the clients' own savings from which loans can be disbursed to the group members while linking the well-performing groups to banks for access to bank loans, is such a new approach. It is practised by The Leprosy Mission Trust in India. In Africa, some international NGOs started with similar 'community based saving and lending groups'.

Needs assessment for income generation training of youths in leprosy families of a leprosy village in Myanmar.

After Myanmar eliminated leprosy in 2003, the prevention of disability (POD), as well as prevention of worsening disabilities (POWD) and rehabilitation became a new agenda, which is one of three national strategies of leprosy control beyond 2005. Since the training needs for income generation for youths living in leprosy villages were not well known, a small-scale survey was conducted in May 2005. This study found that the youths in Mayanchaung village, Yangon Division, were eager to receive training on income generation. After training they wanted to practice and improve their skills with the resources available, because they perceived that a short training course would not enable them to get a proper job. Although they were fully aware of income generation skills, they found it difficult to adequately consider issues such as resources for practicing skills after training, social marketing, and seeking job opportunities. They also felt that mediators could be helpful between villagers and external customers / retailers. On the other hand, the elders, most of whom had disabilities, wanted the youths to stay in the village to take care of them. A basic sewing and stitching training course that was planned to match the study results was produced in January 2006. After 11 months it was observed that a newly opened sewing workshop was busy operating 12 sewing machines because of a big order of making primary school uniforms. How effective the needs assessment was still unknown, but it was found that prior need assessment activities followed by a training course upon the real needs might promote the proper processes of social rehabilitation of youths in a leprosy village of Myanmar.

[Study on the living condition of people affected by leprosy in Guizhou province].

OBJECTIVE: To study the marriage status, labour ability, income and other living condition of people affected by leprosy, and to provide information on prevention, cure and salvation programs from the government. METHODS: Based on the standardized national criteria and method, all registered people affected by leprosy in the whole province were asked to fill in a nationally standardized Form. RESULTS: Out of the 13,034 cases, 91.19% were farmers and only 13.01% of the teenagers were at school. On 12,816 patients at age for marriage, there were more unmarried males than females, more living in the leprosy villages than those living outside of the leprosy village (P < 0.01). Disability rate in leprosy villages was seen more than outside of the leprosy village. Per capita average annual income for the people affected by leprosy was only half of the average individual income in the whole province and 1/4 of the individual income in the nation. CONCLUSION: The living condition of those leprosy-affected people, particularly living in leprosy villages, called for special attention and the government should take comprehensive prevention to publicize the knowledge on leprosy to reduce fear and discrimination against them.

Should nutritional status evaluation be included in the initial needs assessment of leprosy patients with disability prior to socio-economic.

Because of the large numbers of leprosy patients with disability and the limited resources available, it is important that socio-economic rehabilitation (SER) is targeted towards those who are most in need. Towards this purpose, current assessments of leprosy patients prior to initiating SER include the evaluation of income, assets and household possessions. Conspicuously absent is the nutritional assessment of the patient. In the absence of weight loss associated with illness, population studies indicate that undernutrition reflects poor socio-economic conditions. In this study of 151 cured leprosy patients with disability, 57% of the patients were found to be undernourished using body mass index (kg/m2) derived from body weight and height, and 10% of the patients were severely undernourished (grade III). Undernutrition in the patients was poorly though significantly correlated with personal income (r = 0.18, P < 0.05). Total household income, reported amount of money spent on food and estimated cereal intakes were not correlated with the BMI of the patient, possibly due to reporting bias and other methodological issues. We propose the inclusion of nutritional status evaluation by anthropometry as part of the initial screening of leprosy patients prior to instituting SER. We believe that this simple and objective evaluation can add to the assessment of 'threat' of economic deprivation or actual economic 'dislocation', and thus help in the prioritization of leprosy patients for SER.

The effect of leprosy-induced deformity on the nutritional status of index cases and their household members in rural South India: a socio-economic perspective.

OBJECTIVES: To determine whether the socioeconomic and nutritional status of cured leprosy patients with residual deformity, and their household members, was lower than that of cured leprosy patients without deformity. DESIGN: Cross-sectional study. SUBJECTS: One hundred and fifty-five index cases with deformity, 100 without deformity. Also 616 household members comprising 48% of the total members enumerated. MEASUREMENTS: Nutritional status was evaluated using anthropometry. Disease characteristics, socio-economic parameters and household information were recorded using a questionnaire. RESULTS: Index cases with deformity had lower community acceptance (P<0.001), and employment (P<0.001) than those cases without deformity. Households of index cases with deformity had a lower income (P<0.01) and a lower expenditure on food (P<0.05). The presence of deformity (odds ratio (OR): 2.1-3.2, P<0.01), unemployment (OR: 2.3-4.3, P<0.01) and female gender (OR: 2.4, P<0. 01) significantly increased the risk of index cases being undernourished, as judged by body mass index (BMI) alone, or BMI and mid-upper arm circumference. A low BMI (<18.5) in the index case significantly increased the odds of other adults (OR 2.2), adolescents (OR 2.9-3.8) and children (OR 2.2) in the household being undernourished. CONCLUSIONS: Cured leprosy index cases with physical deformity are more undernourished than index cases without deformity. This is associated with a reduced expenditure on food, possibly brought on by increased unemployment, and a loss of income. Undernutrition in the index case increases the risk of undernutrition in other members of the family. European Journal of Clinical Nutrition (2000) 54, 643-649.

Health care expenditures and GDP: panel data unit root test results.

This short paper presents unit root test results for time series on per capita national health care expenditures and gross domestic product in the OECD. Unlike the country-by-country test used by [Hansen, P., King, A., 1996. The determinants of health care expenditure: A cointegration approach. J. Health Econ, 15, 127-137], the test we employ exploits the panel nature of the OECD data. Using this approach, we are able to reject the null hypothesis that these series contain unit roots. No single test is likely to be definitive in this rapidly-evolving area of econometric research; however, our results help to mitigate concern that panel data analyses of national health care expenditures are misspecified.