Perceived Stigma towards Leprosy among Community Members Living Close to Nonsomboon Leprosy Colony in Thailand.

BACKGROUND: Interpretation of Leprosy as a sickness differs among society. The set of beliefs, knowledge and perceptions towards a disease play a vital role in the construction of stigma towards a disease. The main purpose of this study was to explore the extent and correlates of the perceived stigma towards leprosy in the community living close to the leprosy colony in Non Somboon region of Khon Kaen Province of Thailand. METHODS: A cross-sectional study was conducted among 257 leprosy unaffected community participants, above the age of 18 who were living close to the Leprosy colony in Non Somboon region of Thailand. Each participant was asked a questionnaire containing characteristics of the participants in terms of socio-demographic background and knowledge regarding the disease. In addition perceived stigma towards leprosy was measured using EMIC (Explanatory Model Interview Catalogue) questionnaire. RESULTS: Among EMIC items, shame or embarrassment in the community due to leprosy was felt by 54.5%, dislike to buy food from leprosy affected persons were 49.8% and difficulty to find work for leprosy affected persons were perceived by 47.1%. Higher total EMIC score was found in participants age 61 years or older (p = 0.021), staying longer in the community (p = 0.005), attending fewer years of education (p = 0.024) and who were unemployed (p = 0.08). Similarly, perceptions about leprosy such as difficult to treat (p = 0.015), severe disease (p = 0.004) and punishment by God (p = 0.011) were significantly associated with higher perceived stigma. CONCLUSIONS: Perceived stigma towards leprosy was found highest among participants with age 61 years or older, longer duration of stay in community close to the leprosy colony, lower duration of education and participants who were unemployed had higher perceived stigma. Similarly, participants with perceptions of leprosy such as difficult to treat, severe disease and punishment by God had higher perceived stigma towards leprosy. There is an urgent need of stigma reduction strategies focused on education and awareness concerning leprosy.

Prevalence of infectious diseases of immigrant workers receiving health examinations at Rajavithi Hospital.

BACKGROUND: There are rapidly increasing numbers of immigrant workers coming for jobs in Thailand. These immigrant workers often harbor some serious communicable diseases. OBJECTIVE: To describe the prevalence of infectious diseases in these immigrant workers. MATERIAL AND METHOD: This is a retrospective study of immigrant workers who presented for check-ups needed for work permits at Rajavithi Hospital during 1 January 2008 to 31 December 2010. They were examined for serious infectious disease including pulmonary TB, elephantiasis, leprosy, syphilis and malaria. Their health status was analyzed. RESULTS: A total of 102,090 immigrant workers were examined. The majority of cases were female (58.4%) and 94.3% of the population was under the age of 40. Workers from Burma constituted the most cases, (78.9%), followed by workers from Laos (14.0%) and Cambodia (7.0%). The prevalence of infectious diseases in all workers was 1,612.3 cases per 100,000 population. Patients with pulmonary TB, elephantiasis, leprosy, syphilis and malaria were 1,112.7, 7.8, 4.9, 465.3 and 21.5 cases per 100,000 population respectively. The prevalence of TB in Burmese, Lao and Cambodian workers was 1,119.3, 885.9 and 1,493.2 cases per 100,000 population respectively. The prevalence of syphilis in Burmese, Lao and Cambodian workers was 467.8, 258.1 and 851.2 cases per 100,000 population respectively. CONCLUSION: Immigrant workers with infectious diseases were 1,612.3 cases per 100,000 population. Those harboring these serious transmitted diseases may be an important factor in these diseases becoming widespread in Thailand.

SNP genotypes of Mycobacterium leprae isolates in Thailand and their combination with rpoT and TTC genotyping for analysis of leprosy distribution and transmission.

Based on the discovery of three single nucleotide polymorphisms (SNPs) in Mycobacterium leprae, it has been previously reported that there are four major SNP types associated with different geographic regions around the world. Another typing system for global differentiation of M. leprae is the analysis of the variable number of short tandem repeats within the rpoT gene. To expand the analysis of geographic distribution of M. leprae, classified by SNP and rpoT gene polymorphisms, we studied 85 clinical isolates from Thai patients and compared the findings with those reported from Asian isolates. SNP genotyping by PCR amplification and sequencing revealed that all strains like those in Myanmar were SNP type 1 and 3, with the former being predominant, while in Japan, Korea, and Indonesia, the SNP type 3 was found to be more frequent. The pattern of M. leprae distribution in Thailand and Myanmar is quite similar, except that SNP type 2 was not found in Thailand. In addition, the 3-copy hexamer genotype in the rpoT gene is shared among the isolates from these two neighboring countries. On the basis of these two markers, we postulate that M. leprae in leprosy patients from Myanmar and Thailand has a common historical origin. Further differentiation among Thai isolates was possible by assessing copy numbers of the TTC sequence, a more polymorphic microsatellite locus.

Potential effect of the World Health Organization's 2011-2015 global leprosy strategy on the prevalence of grade 2 disability: a trend analysis.

OBJECTIVE: To assess different countries' chances of attaining the 2011-2015 global leprosy target set by the World Health Organization (WHO) and to assess the strategy's effect on the prevalence of grade 2 disability (G2D). METHODS: Trends in G2D rate were analysed for Brazil, China, India and Thailand and figures were compared with the WHO target: a 35% decrease by 2015 relative to the 2010 baseline. To estimate the prevalence of G2D in 2015 and 2035 for each country three assumptions were made: (i) maintenance of the current trend; (ii) attainment of the WHO target, and (iii) reduction of G2D by 50% every 5 years relative to 2010. FINDINGS: Since 1995, the G2D rate has decreased every 5 years in Brazil, China, India and Thailand by 12.7% (95% confidence interval, CI: 6.6-18.3), 7.7% (95% CI: 1.1-12.8), 53.7% (95% CI: 38.1-65.4) and 35.9% (95% CI: 23.4-46.3), respectively. New cases with G2D detected after 2010 will contribute 15% (Brazil), 3% (China), 2.5% (India) and 4% (Thailand) to the total prevalence of G2D in 2015. If no policies are changed, between 2015 and 2035, the prevalence of G2D will decrease by more than half in China, India and Thailand, and by 16% in Brazil. CONCLUSION: The implications of attaining the WHO target are different for each country and using indicators other than G2D prevalence will help monitor progress. The strategy will not immediately reduce the prevalence of G2D, but if it is applied consistently over the next 25 years, its long-term effect can be substantial.

Molecular epidemiology of leprosy based on VNTR typing in Thailand.

Recently about 500 new cases of leprosy have been reported each year in Thailand. In addition to a steady rate of new case detection, Thailand is in Southeast Asia where leprosy is endemic in neighbouring countries; therefore, strain differentiation could be useful in tracing origins and routes of infection, and general leprosy surveillance. To identify suitable markers for differentiation of M. leprae strains in different global geographic regions and to determine the applicability of a systematic genotyping method for tracing leprosy transmission, variable nucleotide tandem repeats (VNTRs) of 14 loci were evaluated using DNA extracts from a total of 97 skin biopsies and slit skin smear samples. The alleles per locus ranged from 2-26 providing adequate strain differentiation. Microsatellite loci (GAA)21, (AT)17 are highly polymorphic followed by (GTA)9, (AC)8a, (AC)8b, and (AC)9. The minisatellites 6-7, 21-3 and 27-5 exhibited a limited number of alleles. The repeat of 23-3 showed no polymorphism. Overall, the strain types can be divided into two distinct Thai groups, according to the alleles at the (GGT)5 and 21-3 loci. However, there are no obvious geographical patterns of distribution of VNTR strain types. Closely matched VNTR profiles found in household members of two multi-case families suggested infection through a common source.

Assessment of subclinical leprosy infection through the measurement of PGL-1 antibody levels in residents of a former leprosy colony in Thailand.

OBJECTIVES: To investigate the hypothesis that there is continuing subclinical M. leprae infection, contributing to ongoing transmission of leprosy in Phra-Pradaeng Colony. DESIGN: A sero-epidemiological survey was carried out in Phra-Pradaeng Colony, Thailand between May and August 2005. The clinical and serological examinations were conducted in 398 people, aged 3-84 years (average 50 years), comprising 196 males and 202 females. RESULTS: Measurement of serum anti PGL-I antibodies in eligible contacts and ex-patients showed that 18 people (4.5%) were seropositive, six people (1.5%) were strongly positive and 374 people (94.0%) were seronegative. All six people who were strongly seropositive were ex-patients; five of them had no evidence of active leprosy but the sixth person had relapsed BL leprosy with a reversal reaction. CONCLUSIONS: This study failed to confirm the hypothesis that there was ongoing subclinical M. leprae infection. More appropriate diagnostic methods and a total survey of the colony should be considered to further clarify this problem.

Close contacts with leprosy in newly diagnosed leprosy patients in a high and low endemic area: comparison between Bangladesh and Thailand.

BACKGROUND: As part of a larger study of the role of close contacts in the transmission of M. leprae, we explored whether the proportion of newly detected cases with a family history of leprosy differs with different incidence rates of leprosy in a population. METHODS: Retrospective analysis was performed of contacts of all new leprosy patients diagnosed during a 10-yr period in well-established leprosy control programs in Thailand and Bangladesh. By our definition, a contact group consisted of the new case and of past and present cases who were relatives and in-laws of the new case. For a new case, the nearest index case was defined on the basis of time of onset of symptoms for the cases in the contact group, in combination with the level of closeness of contact between these cases and the new case. Three contact levels were distinguished. In Bangladesh these levels were defined as 'kitchen contact'; 'house contact'; and 'non-house contact'. In Thailand comparable levels were defined as 'house contact'; 'compound contact'; and 'neighbor contact'. RESULTS: In Bangladesh 1333, and in Thailand 129 new patients were included. The average new case detection rate over 10 yrs was 50 per 100,000 general population per year in Bangladesh, and 1.5 per 100,000 in Thailand. In the high endemic area 25% of newly detected cases were known to belong to a contact group and were not the index case of this group, whereas in the low endemic area 62% of newly detected cases had these characteristics. The distribution of the nearest index cases over the three contact levels was comparable in both areas. Just over half of the nearest index cases were found within the immediate family unit ('kitchen' in Bangladesh; 'house' in Thailand). CONCLUSION: The results indicate that in a low endemic area a higher proportion of newly detected leprosy cases have a family history of leprosy compared to a high endemic area. Different contact levels and their relative risks to contract leprosy need to be established more precisely. In high endemic situations the circle of contacts that should be surveyed may need to be wider than currently practiced.

Analysis of Mycobacterium leprae genome: in silico searching for drug targets.

The author performed a database search to find the recorded complete genes with complete sequences of Mycobacterium leprae and studied their homology to human genomes by BLAST method. From a total of 35 genes, the potential candidates for further target-based drug development were identified.

Leprosy and tuberculosis in Iron Age Southeast Asia?

The recent excavation of a sample of 120 human skeletons from an Iron Age site in the valley of the Mun River, a tributary of the Mekong River on the Khorat Plateau in northeast Thailand, has provided the largest sample from this period in the region to date. This paper reviews three individuals from the sample with pathological changes for which the differential diagnosis includes systemic infectious disease. In two of these, both males with lesions of the hands and feet, leprosy and psoriatic arthritis are discussed as differential diagnoses, with leprosy the most probable. In the third, a female with lesions of the spine, the differential diagnosis includes tuberculosis and nonspecific osteomyelitis. Tuberculosis is the most probable diagnosis. Although the focus of this paper is a presentation of the evidence for infectious disease at Noen U-Loke, the significance of probable diagnoses of mycobacterial diseases for the history of the diseases and for prehistory in mainland Southeast Asia is also briefly discussed.

Monitoring the size of the leprosy problem: which epidemiological indicators should we use?

The purpose of the study was to discuss the interpretation of epidemiological trends in leprosy, using currently available indicators. A number of leprosy-endemic countries and regions were chosen for which epidemiological data have been published for a period of at least 15 years. Using these examples, relative merit of the registered prevalence rate, the case detection rate, the children proportion among new cases and proportion of new cases with grade 2 disability will examined for interpreting the leprosy situation in these countries. Considerable drop of the registered prevalence rates (PR) were evident in all endemic countries. However, this decline was due largely to shortening of treatment and 'cleaning' of leprosy registers and has not been reflected in the annual case detection rates (CDR), except in a few countries. The proportion of new cases with grade 2 impairment had decreased substantially, which indicates earlier case finding. However, the proportion of children among new cases did not change much in the past decade. It is indicate that transmission is still continuing. We reiterate the conclusion of the ILA Technical Forum that the (annual) case detection rate is the most appropriate indicator for monitoring of leprosy situation in a given country or area. Two additional indicators that helped to interpret the CDR were the proportion of new cases with grade 2 impairments, reflecting the delay between occurrence and diagnosis of the disease, and the proportion of children among new cases, which is used as a proxy indicator for recent transmission.

Gender difference in socio-epidemiological factors for leprosy in the most hyper-endemic district of Nepal.

Leprosy which has caused stigma and social ostracism for millennium is nearing elimination worldwide as a public health problem, but the leprosy burden in Nepal is still 4.4 times greater than WHO's target level of less than one case per 10,000 population. Although leprosy affects both the sexes, in most parts of the world males are affected more than females at a ratio of 2:1. The general objective of the study was to investigate the gender difference in socio-epidemiological factors for leprosy. The analytic cross-sectional study was carried out in one of the most hyper endemic district- Dhanusa district of Nepal. Stratified random sampling method was applied for the selection of the patients. Chi-square/Fisher's exact test was applied to assess statistically significant differences in values between males and females. There were 580 leprosy patients (385 male and 195 female) aged above 15 years registered for multi drug therapy between April 1, 2001 to March 31,2002 in the 16 main health centers of the district. Out of 580 patients, 273 patients (183 males and 90 females) were included in the study in order to collect the data on socio-demographics, patient's knowledge on leprosy, treatment seeking behaviour, and social problems faced by the patients. Data were collected using a structured interview schedule. The mean age of the male patients was 45.1 years (range 15-77 years) and female patients were 40.3 years (range 15-75 years). Among male patients 93.4% were married while among female patients 70.0% were married. Among male patients 51.9% were illiterate whereas 71.1% were illiterate among female patients. Most of the patients (69.6%) lived in joint family and the rest in nuclear family. Among male patients, 86.9% had good knowledge about the disease compared to 73.3% among females. This study showed that among the female patients 12.2% were facing high level of social problems, while among male patients only 4.4% were facing the same. About 15% patients had poor treatment seeking behaviors (8.2% among males and 27.8% among females). A significant gender differences among leprosy patients have been found in age distribution, educational status, marital status, caste types, family members, and overall knowledge on the general aspect of leprosy, social problems faced by the patients and treatment seeking behaviour.

High oral prevalence of Candida krusei in leprosy patients in northern Thailand

Although Candida albicans is the most common human yeast pathogen, other Candida species such as C. krusei are now recognized as emerging agents, especially in patients with human immunodeficiency virus (HIV) disease. C. krusei is inherently resistant to the widely used triazole antifungal fluconazole and poses therapeutic problems, especially in systemic candidiasis. In a surveillance study of leprosy patients (with arrested or burnt-out disease) in a leprosarium in northern Thailand, we found a rate of oral carriage of C. krusei (36 per cent) significantly (P smaller 0.05) higher than that for a healthy control group (10 per cent). Among the Candida-positive patients, 16 of 35 (46 per cent) carried C. krusei, while C. albicans was the second most common isolate (12 of 35 patients; 34 per cent). The corresponding figures for the control group were 2 of 13 (15 per cent) and 6 of 13 (46 per cent), respectively. Studies of the antifungal resistance of the C. krusei isolates from patients indicated that all except one of the isolates were resistant to fluconazole, two isolates were resistant to ketoconazole, and all isolates were sensitive to amphotericin B. Evaluation of their genetic profiles by randomly amplified polymorphic DNA analysis with three different primers and subsequent analysis of the gel profiles by computerized cluster-derived dendrograms revealed that the C. krusei isolates from patients belonged to 10 disparate clusters, despite the origin from a single locale. These nascent findings indicate an alarmingly high prevalence of a Candida species resistant to a widely used antifungal in a part of the world where HIV disease is endemic.

Present status and future vision of the International Medical Co-operation for Leprosy.

In the year 2002, leprosy situation in Thailand has been steadily progress. However, the prevalence rate and percentage of leprosy patients are still quite high in the North-Eastern part of Thailand. Therefore, we have focused our plan of action 2001-2 on "The strengthening of Leprosy Elimination and Prevention of Disability in the North-Eastern Region." The objective of which is to improve and sustain the ability of leprosy related staff to conduct activities such as case finding, complication diagnosis, treatment of disabilities, rehabilitation, supervision and evaluation. The International Medical Co-operation for Leprosy in 2001, we received funds from Netherland Leprosy Relief Association (NLR) for 9 programmes concerning training of leprosy for health officers and assessment of the quality of life for leprosy affected persons living in northeastern colonies. There are 3 training courses of leprosy for new medical doctors, lab technicians from community and provincial hospitals and 2 workshops on Rehabilitation and Development of Leprosy Affected Persons "Quality of Life" under the Germany Leprosy Relief Association (GLRA) support. From Japan we received funding from Sasakawa Memorial Health Foundation (SMHF) for 4 projects in immunological studies since 1997 and 2 projects concerning dental services for Leprosy patients in the north and northeast regions from Umemoto Memorial Dental Service Group (UMDSG). The medical co-operation between Japan and Thailand should increase in many aspects especially, for new chemotherapy, immunotherapy and vaccine study in Leprosy. The future vision of Leprosy, we plan to set up the International Center of Leprosy for medical officers, technicians, etc. for the South-East Asian Countries. You are welcome to join and work together with us.

The occurrence of reactions and impairments in leprosy: experience in the leprosy control program of three provinces in northeastern Thailand, 1987-1995 [correction of 1978-1995]. I. Overview of the study.

AIM: This paper is the first in a series of three reports on the occurrence of reactions and impairments in leprosy in Thailand. This first paper gives a general overview about the methodology of the study, some epidemiological observations, delay in detection, multidrug therapy (MDT) completion rates and relapses. The other two papers report on: II. Reactions and III. Neural and Other Impairments. This study was carried out from 1987 until 1995 in three neighboring provinces in northeastern Thailand. STUDY DESIGN: A population-based, prospective cohort study. STUDY POPULATION: All 640 newly diagnosed leprosy patients in the three provinces, registered between October 1987 and September 1990, were included [420 paucibacillary (PB) and 220 multibacillary (MB)]. This group was followed up (actively and passively) until the end of 1995. METHODS: Patients were found by active and passive case finding. All new, untreated leprosy patients from the area were enrolled and started on the World Health Organization (WHO) MDT (WHO/MDT) regimen. A vertical control service was run by specialized leprosy workers. During treatment the patients received their monthly doses at home. During surveillance the patients were followed up once a year by a special team. Patients were questioned about delay in detection. Treatment completion rates were calculated. The occurrence of reactions and neural and other impairments at the beginning of, during and after treatment was ascertained. After treatment, the occurrence of late reactions and relapses was recorded. RESULTS: A higher frequency of leprosy was found among the male patients, especially in the MB group. However, in the PB group a higher female/male ratio was found in the age group 55 years and older. There was an increase in the detection rate from the youngest age group to the age group 55 years and older, which showed the highest detection rate. Treatment completion rates were high, 95% in both in the PB and MB treatment groups. About 50% of the new cases reported a delay between onset and registration of 1 year or more. By 1995, 93% of the original patient group was still available for follow up. By the end of 1995, 8 PB and 2 MB relapses were recorded.

The occurrence of reactions and impairments in leprosy: experience in the leprosy control program of three provinces in northeastern Thailand, 1987-1995 [correction of 1978-1995]. II. Reactions.

AIM: This is the second paper in a series of three papers on the occurrence of reactions and impairments in leprosy in Thailand, and focuses on the prevalence and incidence of reactions, including silent neuropathy. STUDY DESIGN: A population-based, prospective cohort study. STUDY POPULATION: All 640 newly diagnosed and registered leprosy patients in three neighboring provinces in northeastern Thailand registered between October 1987 and September 1990 were included [420 paucibacillary (PB) and 220 multibacillary (MB)]. This group was followed up (actively and passively) until the end of 1995. METHODS: Clinical data and data on the sensibility and motor function of the eyes, hands and feet were obtained when appropriate. The occurrence of reactions, including silent neuropathy, at the beginning of, during and after treatment was ascertained. During surveillance mild late reactions were also recorded. RESULTS: Severe reversal reactions (RR) at the start of and during treatment were seen in 2.6% [confidence interval (CI) 1.1-4.1] of the PB and 29% (CI 23-35) of the MB patients. In the PB group the majority (82%) of severe RR were found at the start of treatment. In the MB group 35% of the severe RR were found at the start of treatment and another 59% during the first year of treatment. It is shown that there is a statistically highly significant increasing proportion of patients with severe RR starting from tuberculoid and going toward borderline lepromatous. The incidence rate of severe RR during treatment was 1.4 (CI 0.46-4.5) per 100 person-years at risk (PYAR) for PB patients and 12 (CI 9.0-16) per 100 PYAR for MB patients. Late (mild and severe) RR were seen in 2.7% of the PB and 9% of the MB patients (35% of these reactions being considered severe). Late reactions were mainly seen in borderline tuberculoid (PB group) and in borderline lepromatous patients. Recent silent neuropathies were seen at first examination and during treatment in 1.4% of the pB and 4.1% of the MB patients. During surveillance only a few silent neuropathies were seen. If all severe RR, severe erythema nodosum leprosum and silent neuropathies at the start of, during and after treatment were added together, then 53% of the borderline lepromatous and 42% of the lepromatous patients had or developed one or another serious complication in need of steroid treatment.

The occurrence of reactions and impairments in leprosy: experience in the leprosy control program of three provinces in northeastern Thailand, 1987-1995 [correction of 1978-1995]. III. Neural and other impairments.

AIM: This the third paper in a series of three papers on the occurrence of reactions and impairments in leprosy in Thailand, and focuses on the prevalence and incidence of neural and other impairments in leprosy. STUDY DESIGN: A population-based, prospective cohort study. STUDY SUBJECT: All 640 newly diagnosed and registered leprosy patients in three provinces of northeastern Thailand between October 1987 and September 1990 were included [420 paucibacillary (PB) and 220 multibacillary (MB)]. This group of patients was followed up until the end of 1995. METHODS: Clinical data; data on the sensibility and motor function of eyes, hands and feet, and data on wounds and bone loss were obtained where appropriate. The occurrence of neural and other impairments at first examination, during treatment and during surveillance was ascertained. RESULTS: The relationship between impairment prevalence (grade 2 of the combined PB and MB groups and grades 1 and 2 together of the combined PB and MB groups) and duration of disease (before diagnosis) was found to be statistically significant. Increased delay in detection led to increased problems of impairments. Too many patients still develop new/additional impairments while on treatment and thereafter. The incidence of nerve function impairment (NFI) among patients without impairments at first examination while on treatment was 1.7 [ 95% confidence interval (CI) 0.45-4.4] per 100 person-years at risk (PYAR) for the PB group and 12 (CI 8.4-17) per 100 PYAR for the MB group. Additionally, 2% of the PB and 11% of the MB patients who already had impairments at first examination developed new NFI while on treatment. The outcome, comparing the first examination with the last examination during/after surveillance [changes in the voluntary muscle test (VMT), the sensory test (ST), wound count and bone loss], indicated that of the PB patients 3.7% improved, 3.7% got worse and 3.9% kept the same impairment; of the MB patients 19% improved, 18% got worse and 2.9% kept the same impairment. During treatment most of the new/additional impairments were due to new/increase in NFI; during surveillance slightly more than 50% were due to new/increase in NFI. Eighty-three percent of the MB patients without impairments at first examination who developed NFI during treatment improved (completely or partially) after receiving prednisolone. Only 62% of the MB patients with a grade 1 impairment at first examination and who developed a severe reaction or recent silent neuropathy improved after receiving prednisolone. There is a need for an indicator to measure new/additional impairments while on treatment and thereafter. It is proposed to measure changes in impairment by measuring changes in VMT, ST, wound count and bone loss.