Delayed detection of leprosy cases: A systematic review of healthcare-related factors.

BACKGROUND: In new leprosy cases, grade 2 disability (G2D) is still a public health burden worldwide. It is often associated with the delayed leprosy diagnoses that healthcare systems should play a crucial role in preventing. The aim of this systematic review was to identify healthcare factors related to delays in case detection in leprosy. METHODS: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) was used as a guideline in this research. The study protocol was registered in the PROSPERO (International Prospective Register of Systematic Reviews) with reference code CRD42020189274. Data was collected from five electronic databases: Embase, Medline All Ovid, Web of Science, Cochrane CENTRAL, and the WHO Global Health Library. RESULTS: After applying the selection criteria for original empirical studies, and after removing duplicates, we included 20 papers from 4313 records. They had been conducted in ten countries and published between January 1, 2000, and January 31, 2021. We identified three categories of healthcare factors related to delayed case. 1) Structural factors, such as i) financial and logistic issues, and geographical circumstances (which we classified as barriers); ii) Health service organization and management including the level of decentralization (classified as facilitators). 2) Health service factors, such as problems or shortages involving referral centers, healthcare personnel, and case-detection methods. 3) Intermediate factors, such as misdiagnosis, higher numbers of consultations before diagnosis, and inappropriate healthcare services visited by people with leprosy. CONCLUSIONS: Delays in leprosy case detection are due mainly to misdiagnosis. It is crucial to improve the training and capacity of healthcare staff. To avoid misdiagnosis and reduce detection delays, national leprosy control programs should ensure the sustainability of leprosy control within integrated health services.

Stakeholder perspectives on an integrated package of care for lower limb disorders caused by podoconiosis, lymphatic filariasis or leprosy: A qualitative study.

BACKGROUND: Lower limb disorders including lymphoedema create a huge burden for affected persons in their physical and mental health, as well as socioeconomic and psychosocial consequences for them, their families and communities. As routine health services for the integrated management and prevention of lower limb disorders are still lacking, the 'Excellence in Disability Prevention Integrated across Neglected Tropical Diseases' (EnDPoINT) study was implemented to assess the development and delivery of an integrated package of holistic care-including physical health, mental health and psychosocial care-within routine health services for persons with lower limb disorders caused by podoconiosis, lymphatic filariasis and leprosy. METHODOLOGY/PRINCIPAL FINDINGS: This study was part of the first of three phases within EnDPoINT, involving the development of the integrated care package. Focus group discussions and key informant interviews were undertaken with 34 participants between January-February 2019 in Awi zone, Ethiopia, in order to assess the draft care package's feasibility, acceptability and appropriateness. Persons affected by lower limb disorders such as lymphoedema experience stigma, exclusion from families, communities and work as well as physical and financial hardship. Beliefs in disease causation inhibit affected persons from accessing care. Ignorance was a barrier for health care providers as well as affected persons. Training and education of affected persons, communities and caregivers is important in improving care access. It also requires time, space, materials and financial resources. Both top-down and grass roots input into service development are key, as well as collaboration across stakeholders including charities, community leaders and "expert patients". CONCLUSIONS/SIGNIFICANCE: This study highlighted the need for the EnDPoINT integrated care package and provided suggestions for solutions according to its three aspects of integrated care (integration into routine care; integration of mental health and psychosocial care; and integration of care across the three diseases), thereby giving support for its feasibility, acceptability and appropriateness.

The implementation of an integrated e-leprosy framework in a leprosy control program at primary health care centers in Indonesia.

BACKGROUND AND OBJECTIVE: The implementation of health information systems (HIS) could overcome obstacles in human resources and infrastructure at primary health care centers (PHCs). This study involved an e-Leprosy framework being integrated into the real setting of a leprosy control program in Indonesia. The objectives of this implementation study were to integrate e-Leprosy into a leprosy control program at 27 PHCs in Pekalongan District. Central Java Province, Indonesia to explore factors related the success or failure of such an implementation regarding the usability, involvement, and acceptance of e-Leprosy by PHC staff and to evaluate the effect of the implementation on leprosy patient attendance at PHCs. This paper is based on the Standards for Reporting Implementation Studies (StaRI) statement. METHOD: This study used mixed methods implementation research with longitudinal analysis and involved two groups of participants: Leprosy Surveillance Officers (LSOs), patients, and the relatives of patients. This study involved four phases consisting of preparation, baseline assessment, intervention, and evaluation. The qualitative study conducted focus group discussions and in-depth interviews. The e-Leprosy program automatically sent SMS reminders regarding leprosy treatment to the LSOs, patients, and patients' relatives every month. FINDINGS: This study determined that LSO had difficulties related to their workloads in PHCs while managing information and monitoring treatment and contact after release from treatment. The baseline assessment phase found that LSOs in Pekalongan District were unfamiliar with email but familiar using the internet. Overall, LSOs had a positive perception of the e-Leprosy program. The usability of this e-Leprosy program tended to increase over time, while acceptance of the e-Leprosy exhibited a significant relationship with computer and internet fluency (r = 0.48, p < 0.05) and age (r = 0.621, p < 0.01). The responsible patients correlated (r = 0.67, p < 0.01) with involvement in the e-Leprosy program. This study revealed that patient reminders increased on-time attendance by 13.9 % (p < 0.01 with OR = 2.41). CONCLUSION: Factors that should be considered during implementation HIS included the digital gap, PHC's staff workload, as well as the level of commitment and leadership in the health office.

Stigma, participation restriction and mental distress in patients affected by leprosy, cutaneous leishmaniasis and Chagas disease: a pilot study in two co-endemic regions of eastern Colombia.

BACKGROUND: Leprosy, cutaneous leishmaniasis (CL) and Chagas disease (CD) are neglected tropical diseases with a high psychosocial burden (PSB). These conditions are endemic in Norte de Santander and Arauca in Colombia, but data on the related PSB are scarce. Therefore, we assessed mental distress, participation restriction and stigma among CD, CL and leprosy patients. METHODS: In 2018, 305 leprosy, CD or CL patients were interviewed using a self-report questionnaire to assess mental distress, participation scale for participation restriction and explanatory model interview catalogue (EMIC) for stigma. Descriptive statistics and the significance of median score differences were compared. RESULTS: Fifty percent of CD patients and 49% of leprosy patients exhibited mental distress, percentages which were significantly higher than that of CL (26%). Twenty-seven percent of leprosy patients experienced participation restriction, which was lower for CL (6%) and CD (12%). Median EMIC scores were significantly higher for leprosy patients than for CD (27%) and CL (17%) patients. CONCLUSIONS: We found high levels of PSB among leprosy, CD and CL patients. Mental distress was highest among CD patients. Participation restriction and stigma were more prevalent in leprosy patients. Rural residence or lower educational status may impact PSB. Further investigation is needed to formulate evidence-based, holistic interventions.

Patients help other patients: Qualitative study on a longstanding community cooperative to tackle leprosy in India.

BACKGROUND: Although leprosy is portrayed as a disappearing disease, leprosy affected persons in India are still suffering massively. Even further, nearly 60% of the world's newly detected cases are appearing from India alone. The problem has exacerbated due to the drastic decrease of global funding after India's official declaration of 'elimination', which did not foster the actual pain of patients beyond prevalence. Leprosy patients have hardships in their lives due to disabilities, stigma and poverty; thus, they require sustained, continuous care even after release from treatment. Yet, current interventions mostly have a vertical, short-term approach, not showing much progress in lightening the burden of leprosy. In contrast, Little Flower Hospital Community (LFHC) in India has been remarkably providing holistic care for thousands of leprosy patients for 35 years. However, there has not been any research conducted to uncover the underlying factors of this longstanding leprosy control model. Therefore, this research explores the in-depth contextual attributes of this hospital community that has been able to successfully provide sustainable care for a long time even without excessive external funds. METHODS AND FINDINGS: This qualitative research used a grounded theory approach, involving 28 in-depth interviews of 11 patients, 13 workers, and 4 board members from the hospital. The interview data were inductively analyzed to examine the contextual factors of the hospital's sustainability. Open coding, axial coding and selective coding were conducted, and Glaser's Six C's model was used to create a theoretical model of the sustainability of LFHC. The fundamental cause of the sustainability was the leprosy patients' strong craving for life with dignity, despite the isolation from the society. The desire resulted in a bottom-up formation of a 'consumer-provider cooperative', where patients mutually support each other with basic treatment learned from experience. The profits earned from the patients' occupational efforts such as dairy farming, cover the costs needed to manage the hospital community, which contributes to economical sustainability. Social sustainability was established through the holistic care including psychosocial, educational, medical, and residential support. The wholesome care socially rehabilitated the patients to be included in the society with satisfaction, social justice and social cohesion. The main limitation of this study is that this study cannot be generalized due to the nature of Grounded Theory based study. CONCLUSIONS: This study investigated the determinants that made LFHC sustainable, and the findings suggested the importance of forming a cooperative community and implementing social rehabilitation for sustainable leprosy control. More exploration on transferring this model to other leprosy colonies will have great impact in maintaining sustainable care for leprosy patients. Furthermore, this research may highlight the importance of sustainable development in policies targeting neglected tropical diseases beyond leprosy as well.

Evidence for Mycobacterium leprae Drug Resistance in a Large Cohort of Leprous Neuropathy Patients from India.

Resistance to anti-leprosy drugs is on the rise. Several studies have documented resistance to rifampicin, dapsone, and ofloxacin in patients with leprosy. We looked for point mutations within the folP1, rpoB, and gyrA gene regions of the Mycobacterium leprae genome predominantly in the neural form of leprosy. DNA samples from 77 nerve tissue samples were polymerase chain reaction (PCR)-amplified for M leprae DNA and sequenced for drug resistance-determining regions of genes rpoB, folP1, and gyrA. The mean age at presentation and onset was 38.2 ± 13.4 (range 14-71) years and 34.9 ± 12.6 years (range 10-63) years, respectively. The majority had borderline tuberculoid leprosy (53 [68.8%]). Mutations associated with resistance were identified in 6/77 (7.8%) specimens. Mutations seen were those associated with resistance to rifampicin, ofloxacin, and dapsone. All the six patients were drug-naive. The clinical and pathological manifestations in this group did not differ from the drug-sensitive group. This study highlights the occurrence of resistance to the standard multidrug therapy and ofloxacin in leprosy. Among the entire cohort, 1/77 (1.3%) showed resistance to rifampicin, 2/77 (2.6%) to dapsone, and 5/77 (6.4%) to ofloxacin. Six new patients showing infection by mutant strains indicated the emergence of primary resistance. Resistance to ofloxacin could be due to frequent use of quinolones for many bacterial infections. The results of the study indicate the need for development of a robust and strict surveillance system for detecting drug resistance in leprosy in India.

Antimicrobial resistance in leprosy: results of the first prospective open survey conducted by a WHO surveillance network for the period 2009-15.

OBJECTIVES: Antimicrobial resistance (AMR) is a priority for surveillance in bacterial infections. For leprosy, AMR has not been assessed because Mycobacterium leprae does not grow in vitro. We aim to obtain AMR data using molecular detection of resistance genes and to conduct a prospective open survey of resistance to antileprosy drugs in countries where leprosy is endemic through a WHO surveillance network. METHODS: From 2009 to 2015, multi-bacillary leprosy cases at sentinel sites of 19 countries were studied for resistance to rifampicin, dapsone and ofloxacin by PCR sequencing of the drug-resistance-determining regions of the genes rpoB, folP1 and gyrA. RESULTS: Among 1932 (1143 relapse and 789 new) cases studied, 154 (8.0%) M. leprae strains were found with mutations conferring resistance showing 182 resistance traits (74 for rifampicin, 87 for dapsone and 21 for ofloxacin). Twenty cases showed rifampicin and dapsone resistance, four showed ofloxacin and dapsone resistance, but no cases were resistant to rifampicin and ofloxacin. Rifampicin resistance was observed among relapse (58/1143, 5.1%) and new (16/789, 2.0%) cases in 12 countries. India, Brazil and Colombia reported more than five rifampicin-resistant cases. CONCLUSIONS: This is the first study reporting global data on AMR in leprosy. Rifampicin resistance emerged, stressing the need for expansion of surveillance. This is also a call for vigilance on the global use of antimicrobial agents, because ofloxacin resistance probably developed in relation to the general intake of antibiotics for other infections as it is not part of the multidrug combination used to treat leprosy.

Introducing leprosy post-exposure prophylaxis into the health systems of India, Nepal and Indonesia: a case study.

BACKGROUND: Leprosy has a wide range of clinical and socio-economic consequences. India, Indonesia and Nepal contribute significantly to the global leprosy burden. After integration, the health systems are pivotal in leprosy service delivery. The Leprosy Post Exposure Prophylaxis (LPEP) program is ongoing to investigate the feasibility of providing single dose rifampicin (SDR) as post-exposure prophylaxis (PEP) to the contacts of leprosy cases in various health systems. We aim to compare national leprosy control programs, and adapted LPEP strategies in India, Nepal and Indonesia. The purpose is to establish a baseline of the health system's situation and document the subsequent adjustment of LPEP, which will provide the context for interpreting the LPEP results in future. METHODS: The study followed the multiple-case study design with single units of analysis. The data collection methods were direct observation, in-depth interviews and desk review. The study was divided into two phases, i.e. review of national leprosy programs and description of the LPEP program. The comparative analysis was performed using the WHO health system frameworks (2007). RESULTS: In all countries leprosy services including contact tracing is integrated into the health systems. The LPEP program is fully integrated into the established national leprosy programs, with SDR and increased documentation, which need major additions to standard procedures. PEP administration was widely perceived as well manageable, but the additional LPEP data collection was reported to increase workload in the first year. CONCLUSIONS: The findings of our study led to the recommendation that field-based leprosy research programs should keep health systems in focus. The national leprosy programs are diverse in terms of organizational hierarchy, human resource quantity and capacity. We conclude that PEP can be integrated into different health systems without major structural and personal changes, but provisions are necessary for the additional monitoring requirements.

Possible cases of leprosy from the Late Copper Age (3780-3650 cal BC) in Hungary.

At the Abony-Turjányos dulo site, located in Central Hungary, a rescue excavation was carried out. More than 400 features were excavated and dated to the Protoboleráz horizon, at the beginning of the Late Copper Age in the Carpathian Basin, between 3780-3650 cal BC. Besides the domestic and economic units, there were two special areas, with nine-nine pits that differed from the other archaeological features of the site. In the northern pit group seven pits contained human remains belonging to 48 individuals. Some of them were buried carefully, while others were thrown into the pits. The aim of this study is to present the results of the paleopathological and molecular analysis of human remains from this Late Copper Age site. The ratio of neonates to adults was high, 33.3%. Examination of the skeletons revealed a large number of pathological cases, enabling reconstruction of the health profile of the buried individuals. Based on the appearance and frequency of healed ante- and peri mortem trauma, inter-personal (intra-group) violence was characteristic in the Abony Late Copper Age population. However other traces of paleopathology were observed on the bones that appear not to have been caused by warfare or inter-group violence. The remains of one individual demonstrated a rare set of bone lesions that indicate the possible presence of leprosy (Hansen's disease). The most characteristic lesions occurred on the bones of the face, including erosion of the nasal aperture, atrophy of the anterior nasal spine, inflammation of the nasal bone and porosity on both the maxilla and the bones of the lower legs. In a further four cases, leprosy infection is suspected but other infections cannot be excluded. The morphologically diagnosed possible leprosy case significantly modifies our knowledge about the timescale and geographic spread of this specific infectious disease. However, it is not possible to determine the potential connections between the cases of possible leprosy and the special burial circumstances.

The leprosarium of Saint-Thomas d'Aizier: The cementochronological proof of the medieval decline of Hansen disease in Europe?

This study compares the adult survivorship profiles of people interred in the Saint-Thomas d'Aizier leprosarium, estimated by cementochronology, to eight archaeological series in northern France dated from Late Antiquity to the Late Middle Ages, periods of significant visibility for Hansen's disease (leprosy). The goals are to understand the impact of leprosy on various social groups and to explore the cause of leprosy's decline by analyzing male and female fertility. Survival rates differed between medieval leprosy-free sites and the Saint-Thomas d'Aizier leprosarium, although this difference was statistically significant only for the female leprosarium sample. The selective female frailty, a consequence of social exclusion and the collapse of the quality of life, combined with the infertility of lepromatous couples, offer a multi-causal explanation to the end of the expansion and then decline of leprosy in southern and western European countries.

Tuberculosis and leprosy in Italy: new skeletal evidence.

Tuberculosis (TB) and leprosy are infections caused by Mycobacteria. This paper documents new skeletal evidence in Italy from the Iron Age site of Corvaro (Central Italy; 5th century BCE) and the Roman site of Palombara (Central Italy; 4th-5th century CE), and briefly reviews the extant evidence for these infections in Italy. The skeletal evidence for TB in Italy is more ancient than for leprosy, and is more common. The oldest evidence for both mycobacterial diseases is in the North of Italy, but this could be by chance, even if biomolecular models suggest a land route from the East to central Europe, especially for leprosy.

Leprosy--evolution of the path to eradication.

Leprosy is among the world's oldest and most dreaded diseases and it has been synonymous with stigma and discrimination due to the hideous deformities it produced, mystery around its aetiology and transmission and lack of any effective remedy till recently. Leprosy control started with the use of chaulmoogra oil and for the last three decades, multi drug therapy (MDT) has been our main tool against leprosy. In the last two decades, the reported global prevalence of active leprosy infection has dropped by almost 90 per cent by the combined efforts of the World Health Organization (WHO), local governments, health professionals, and non-governmental organizations (NGOs), however, a parallel drop in the incidence or new case detection rate (NCDR) has not occurred. From 1994 through 2011, more than 100,000 new cases are being detected annually, of whom maximum case load is from India. There is need for research on tools for early diagnosis, short and effective treatment, and prevention of deformities and disabilities. Evaluating the role of immunotherapy and immunoprophylaxis will also lead us to better understanding of their mode of action. Further molecular analysis of Mycobacterium leprae genome may provide the requisite basis for all this. The current reality is that there is a need to sustain and provide quality leprosy services to all persons through general health services, including good referral system. All these provisions in the integrated health care approach will go a long way in further reducing the stigma. Efforts need to be made to reduce deformity through early detection, self care, physiotherapy and reconstructive surgery and developing sound surveillance systems. With all the remarkable achievements in the fight against leprosy, the stage is now set for the final assault. It is hoped that with the efforts of all the stake holders and strong political will, the disease will be eradicated in the near future.

Avaliação dos pacientes com hanseníase multibacilar submetidos ao esquema terapêutico substitutivo / Evaluation of multibacillary patients undergoing replacement regimen

O tratamento da hanseníase tem como objetivo a cura bacteriológica que interrompe a transmissão, a cura clínica que devolve bem estar ao paciente e a redução das incapacidades permanentes, sendo considerado um ponto estratégico para o controle da endemia e para sua eliminação como problema de saúde pública. Entretanto, as medicações da poliquimioterapia podem causar eventos adversos, levando a desfechos clínicos desfavoráveis, prejudicando a evolução clínica desses pacientes, podendo contribuir para o abandono da poliquimioterapia padrão. O esquema terapêutico substitutivo é indicado para pacientes que apresentam intolerância a poliquimioterapia padrão. Este estudo teve como objetivo avaliar a evolução clínica dos pacientes multibacilares tratados com esquema terapêutico substitutivo preconizado pelo Ministério da Saúde, comparando-os com aqueles submetidos ao esquema padrão (PQT/OMS – 12 doses) para o tratamento da hanseníase. Adicionalmente, pretendese descrever os principais eventos adversos que levaram a troca do esquema padrão. Foi realizado um estudo retrospectivo, utilizando uma coorte de 435 pacientes de hanseníase multibacilares registrados no Ambulatório Souza Araújo no período de janeiro de 1998 a dezembro de 2009. Os pacientes foram divididos em dois grupos: grupo 1 composto por 390 pacientes que realizaram tratamento com a poliquimioterapia padrão e o grupo 2 por 45 pacientes que realizaram tratamento com poliquimioterapia substitutiva. Os desfechos clínicos utilizados para comparação dos dois esquemas terapêuticos foram: evolução da carga bacilar, evolução do grau de incapacidade física e evolução da ocorrência de episódios reacionais após a alta da PQT/OMS, comparando com o esquema padrão. Para isso, foi realizado um estudo retrospectivo, utilizando uma coorte de pacientes de hanseníase multibacilares registrados no Ambulatório Souza Araújo (Laboratório de Hanseníase/IOC/Fiocruz) no período de janeiro de 1998 a dezembro de 2009...(AU)

The treatment of leprosy aims to bacteriological cure that stops transmission, clinical cure that returns the patient welfare and reduce permanent disability and is considered a strategic point for disease control and elimination as a public health problem. However, medications can cause multidrugtherapy adverse events leading to unfavorable clinical outcomes, impairing the clinical outcomes of patients and may contribute to the abandonment ofstandard polychemotherapy. The replacement regimen is indicated for patients who are intolerant to standard polychemotherapy. This study aimed to evaluate the clinical outcomeof patients treated with multibacillary regimen substitute recommended by the Ministry of Health, comparing them with those undergoing standard regimen (WHO / MDT - 12 doses)for the treatment of leprosy. Additionally, we intend to describe the main adverse events that led to the exchange of the default schema. We conducted a retrospective study using a cohort of 435 patients with multibacillary leprosy recorded in Ambulatory Souza Araújo fromJanuary 1998 to December 2009. Patients were divided into two groups: group 1 comprised of 390 patients who underwent standard treatment with multidrug therapy and group 2 of 45patients who underwent treatment with multidrug therapy replacement. Clinical outcomes used to compare the two regimens were: evolution of bacterial load, evolution of physical disability and evolution of the occurrence of reactional episodes after discharge from MDT /WHO, compared with the standard regimen. For this, we conducted a retrospective study using a cohort of multibacillary leprosy patients registered at the Clinic Souza Araújo(Leprosy Laboratory / IOC / Fiocruz) from January 1998 to December 2009...

The production of social discourse on Hansen' disease and health education materials in Brazil: a skin patch as something harmless or a serious disease?

AIMS: Hansen's disease is endemic in Brazil and government control programmes promote publicity campaigns to increase the detection of new cases through the production and distribution of educative material. OBJECTIVES: This study analyses a set of 276 educational materials produced by governmental and non-governmental organisations that work to control Hansen's disease in Brazil. It describes the content of the materials and the way the issues were approached. DESIGN: It is a qualitative study that adopts the theoretical and methodological framework of the semiology of social discourse. RESULTS: Analysis reveals that the relations between the enunciator and recipient of the materials are asymmetrical as a result of the technical and educational language employed. Biomedical information forms the basis for social representations an practices of Hansen's disease, as opposed to historical collective knowledge of 'leprosy'. The prioritised topics are: signs and symptoms of the disease, treatment stigma, cure and surveillance. CONCLUSIONS: The institutionalisation of public education on Hansen's disease in Brazil was not limited simply to the change of terminology from 'leprosy' to 'Hansen's disease,' but was shaped also by new educational practices. It is recommended that the evaluation and production of new materials be incorporated into the set of activities already carried out in health centres so as to expand the discussion on content, language and the best way to address the disease in the materials.

Analysis of newly detected leprosy in Sohag Governorate, Upper Egypt, 2004-2008.

INTRODUCTION: Leprosy is a chronic and complex infectious illness; the new-case detection rate is better than prevalence as an indicator of disease trends. This study presents an analysis of pattern of new cases of leprosy detected annually from 2004 to 2008 in Sohag Governorate, Upper Egypt. PATIENTS AND METHODS: Data about patients with newly diagnosed leprosy were collected from Sohag leprosy hospital, the main referral centre in the governorate. Case detection rates (CDR) were calculated for each year by dividing the newly diagnosed cases by mid-year populations for the same year. RESULTS: 587 patients were newly diagnosed between 2004 and 2008. The mean age of patients at diagnosis was 34 years, 62% were males, and 11% were children below 15 years of age. The overall leprosy case detection rate was 3-1/100,000 population and it decreased from 3.4/100,000 population in 2004 to 2.8/100,000 population in 2008. Ninety three percent were classified as multibacillary, and 20.4% had Grade 2 disability at diagnosis. CONCLUSIONS: Leprosy remains a health problem in Sohag Governorate. It is possible that new cases are being detected late owing to inadequate community awareness of the disease. Leprosy control activities should be provided in primary health care units in order to detect new cases, and continued surveillance is required to detect relapses and to ensure good patient compliance with treatment.

Effectiveness of social skills training for reduction of self-perceived stigma in leprosy patients in rural India--a preliminary study.

OBJECTIVES: To assess the effectiveness of social skills training in leprosy patients to raise self-esteem and reduce self-perceived stigma. DESIGN: Five leprosy patients were given 10 day-long group-sessions of social skills training over 3 weeks. Training involved: identification of the emotions and concerns of patients when interacting socially; analysis of positive and negative social interactions and non-verbal and verbal skills training. Role-plays, videos and live models were used. Self-esteem and a reduction in self-perceived stigma were assessed qualitatively before and after training using semi-structured interviews. Assessment of change was scored under the indicators: self-perception, family, wider community and job. Patients were assessed for displaying new ways of interacting with people and changes in expectations for the future. RESULTS: Qualitative analysis of the interviews before and after training suggested that social skills training could raise the self-esteem of leprosy patients and combat self-perceived stigma. Increase in self-esteem, as evident through the verbal interactions with the interviewers and behavioural changes in the community, were noted in the majority of patients. CONCLUSION: Social skills training along with counseling may be able to increase the self-esteem of leprosy patients, and so be a useful part of leprosy rehabilitation schemes to try and combat the stigma of leprosy.

Can the skin smear examination in NLEP be reconsidered?

Slit and skin smear examination is an important laboratory test which was made optional in the NLEP. In a laboratory managed by LEPRA Society, this test was provided to voluntary reporting cases and those referred by the general health service institutions of the area. Total cases tested were 1180, out of which 152 (12.9%) were positive. Of the 152 smear reports, 121 were from Koraput district and constitute the sample for this study. Regarding the spread of site wise highest BI, 56% cases had BI of 3.1+ to 6+. Of the 121 cases, 112 (92.6%) cases completed 12 doses of MDT. Seventy patients, from whom detailed information was collected by personal contact, responded well to MDT resulting in regression of lesions. Out of them, 46 cases had repeat smear showing negative smear in 39% and decline of 81 in the rest of cases. There are 16 contact cases with 2 family clusters. A rough block-wise mapping showed 4 strata with a dense clustering in the urban area where the laboratory facility is available. The probable reasons for uneven distribution of cases and causes for late diagnosis were discussed. The study reflects the leprosy problem in urban pockets which high infection pool. Together these two factors remain unexposed due to winding up of smear labs and pose a potential threat to elimination. The paper also emphasized on the reasons for past failure of the test along with suggestions to revive this facility with minor modifications.

Integration of leprosy in general health system vis-à-vis leprosy endemicity, health situation and socioeconomic development: observations from Chhattisgarh & Kerala.

This study looked at the integration of leprosy services in the GHS in context of health and socioeconomic situations using predefined indicators. It also looked at clients' perception of MDT services. The Indian states of Chhattisgarh and Kerala, which are at two extremes in leprosy endemicity, health situation and socioeconomic development, have been compared using predefined integration indicators related to the training of health workers, availability of MDT services, maintenance of MDT stock and involvement of Sub-centres in leprosy care. Data was collected by surveys of health facilities, sub-centres and communities in the two states, during 2006-2007. Information was collected by interviewing health personnel and clients, checking of records and on the spot observations using specifically designed formats. Results showed that integration is more inclusive in Chhattisgarh and has reached up to Sub-centre level. Both the community and health systems are sensitive and responsive to leprosy as it is perceived to be a major public health threat. But in Kerala, despite integration, it continues as a vertical programme with dependence on specialists and districts hospitals for diagnosis and treatment. MDT stock management is even poorer. Clients' perception towards MDT services are similar in both states.

Clinic-epidemiological evaluation of ulcers in patients with leprosy sequelae and the effect of low level laser therapy on wound healing: a randomized clinical trial.

BACKGROUND: Mycobacterium leprae is the only pathogenic bacteria able to infect peripheral nerves. Neural impairment results in a set of sensitive, motor and autonomic disturbances, with ulcers originating primarily on the hands and feet. The study objectives were to analyze the clinic-epidemiological characteristics of patients attended at one specialized dressing service from a leprosy-endemic region of the Brazilian Amazon and to evaluate the effect of low level laser therapy (LLLT) on wound healing of these patients. METHODS: Clinic-epidemiological evaluation of patients with leprosy sequelae was performed at the reference unit in sanitary dermatology of the state of Pará in Brazil. We conducted anamnesis, identification of the regions affected by the lesions and measurement of ulcer depth and surface area. After that, we performed a randomized clinical trial. Fifty-one patients with ulcers related to leprosy were evaluated, twenty-five of them were randomly assigned to a low level laser therapy group or a control group. Patients were treated 3 times per week for 12 weeks. Outcome measures were ulcer surface area, ulcer depth and the pressure ulcer scale for healing score (PUSH). RESULTS: Ninety-seven ulcers were identified, with a mean (SD) duration of 97.6 (111.7) months, surface area of 7.3 (11.5) cm2, and depth of 6.0 (6.2) mm. Statistical analysis of the data determined that there were no significant differences in the variables analyzed before and after treatment with low level laser therapy. CONCLUSIONS: Ulcers in patients with leprosy remain a major source of economic and social losses, even many years after they have been cured of M. leprae infection. Our results indicate that it is necessary to develop new and more effective therapeutic tools, as low level laser therapy did not demonstrate any additional benefits to ulcer healing with the parameters used in this study. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov as NCT00860717.