Review on the Burden of Leprosy in Ethiopia

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Bear witness for hidden leprosy in a loftier leprosy-endemic setting, Eastern Ethiopia: The application of active case-finding and contact screening

• Kedir Urgesa,
• Kidist Bobosha,
• Berhanu Seyoum,
• Fitsum Weldegebreal,
• Adane Mihret,
• Rawleigh Howe,
• Biftu Geda,
• Mirgissa Kaba,
• Abraham Aseffa

x

• Published: September 2, 2021
• https://doi.org/x.1371/journal.pntd.0009640

Figures

Abstract

Leprosy or Hansen'due south affliction is a disabling infectious disease caused by Mycobacterium leprae. Reliance on the cocky-presentation of patients to the health services results in many numbers of leprosy cases remaining subconscious in the community, which in turn results in a longer filibuster of presentation and therefore leading to more than patients with disabilities. Although studies in Ethiopia show pockets of owned leprosy, the extent of hidden leprosy in such pockets remains unexplored. This study determined the magnitude of hidden leprosy amongst the general population in Fedis District, eastern Federal democratic republic of ethiopia. A community-based cross-exclusive report was conducted in vi randomly selected leprosy-endemic villages in 2019. Health extension workers identified report participants from the selected villages through agile case findings and household contact screening. All consenting individuals were enrolled and underwent a standardized concrete exam for diagnosis of leprosy. Overall, 262 individuals (214 with skin lesions suspected for leprosy and 48 household contacts of newly diagnosed leprosy cases) were identified for confirmatory investigation. The slit pare smear technique was employed to perform a bacteriological examination. Data on socio-demographic characteristics and clinical profiles were obtained through a structured questionnaire. Descriptive statistics and binary logistic regression were used to appraise the clan between the issue variable and predictor variables, and the P-value was set at 0.05. From the 268 individuals identified in the survey, half-dozen declined consent and 262 (97.8%) were investigated for leprosy. Fifteen cases were confirmed as leprosy, giving a detection rate of 5.vii% (95%, CI: three%, ix%). The prevalence of hidden leprosy cases was nine.3 per ten,000 of the population (15/16107). The majority (93.three%) of the cases were of the multi-bacillary type, and three cases were under 15 years of age. 3 cases presented with grade II disability at initial diagnosis. The extent of hidden leprosy was not statistically different based on their sexual activity and contact history difference (p > 0.05). High numbers of leprosy cases were subconscious in the customs. Active cases findings, and contact screening strategies, play an important role in discovering hidden leprosy. Therefore, targeting all populations living in leprosy pocket areas is required for achieving the leprosy emptying target.

Author summary

Leprosy, also called Hansen's disease, is a neglected communicable diseases leading to deformity and disability. Late presentation and hidden cases are the major risks of leprosy-associated disability. Although leprosy endemic pocket areas and class II disability with a loftier proportion were reported in Ethiopia, studies on the burden of hidden leprosy cases are limited. Therefore, this study determined the extent of hidden leprosy cases amidst the full general population in leprosy owned settings in eastern Ethiopia through active example findings and contact tracing. In this community-based survey, leprosy-suspected individuals in the general population and household contacts of newly diagnosed patients with leprosy were included. Health extension workers, community-based health workers in Ethiopia, visited 16107 individuals in the selected villages and 214 leprosy suspects were enrolled in the study based on the clinical signs of leprosy suspects. Leprosy experts examined all leprosy suspects clinically and a skin slit sample was taken for bacteriological examination. Afterward the confirmation of new cases, 48 of their households' contacts were then examined by leprosy experts. Of 262 suspects and household contacts evaluated for leprosy, 15 hidden cases confirmed, giving an overall prevalence of nine.iii per x, 000 population. Nigh of them were Multi-bacillary (MB) type, and one-4th of them were younger than 15 years of age, and three cases presented with grade Ii disability. Hidden leprosy was not statistically associated with participants' sex, age category, and contact history.

Citation: Urgesa K, Bobosha 1000, Seyoum B, Weldegebreal F, Mihret A, Howe R, et al. (2021) Evidence for hidden leprosy in a high leprosy-endemic setting, Eastern Ethiopia: The awarding of active case-finding and contact screening. PLoS Negl Trop Dis 15(9): e0009640. https://doi.org/10.1371/journal.pntd.0009640

Editor: Mauro Sanchez, Academy of Brasilia, BRAZIL

Received: November xix, 2020; Accustomed: July 9, 2021; Published: September 2, 2021

Copyright: © 2021 Urgesa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the manuscript.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have no competing interests.

Introduction

Leprosy or Hansen'due south affliction is a disabling infectious affliction caused by Mycobacterium leprae [1]. It is one of the neglected tropical diseases of public health importance [1,ii]. Leprosy is endemic in poor countries where detection rates remain low despite availability of effective treatment [three]. Though there accept been reductions of about ninety% in the prevalence charge per unit, transmission continues and remains a public wellness event [4].

The global target to eliminate leprosy, a reduction in prevalence to <ane example per x,000 population, was accomplished in 2000[v] and the Earth Wellness Organization (WHO) had prepare a target to interrupt the transmission of leprosy globally by 2020 [6]. Leprosy nevertheless continues to exist a public health problem in different parts of the earth [7], with more 200,000 new cases reported every year [8].

Although Ethiopia achieved the emptying target in 1999, information technology even so has the second-highest disease burden in terms of leprosy in Sub-Saharan Africa (SSA) [ix]. Betwixt 2013 and 2015, iii,500 to iv,000 new leprosy cases were reported to the national tuberculosis and leprosy control program [x]. In 2019, the state reported iii,201 new leprosy patients, of whom 12.viii% presented with a grade II disability, as reported by WHO [8]. Studies in Federal democratic republic of ethiopia also evidenced the persistent prevalence of babyhood leprosy and disabilities with multibacillary (MB) cases in rural southern Ethiopia [eleven,12], which suggested the ongoing transmissions of the illness in the state [thirteen].

Agile case-findings strategies are essential for discovering hidden leprosy and are an important epidemiological tool to minimize cases, reduce incidences of disability due to leprosy, and reduce the transmission of Thou. leprae [14,15]. Moreover, the global leprosy strategy (2016–2020) promotes early on instance detection past the application of active case-finding and contact management in areas of higher endemicity [13].

Withal, in Ethiopia cases of leprosy are detected by examining patients attention wellness facilities (passive instance detection)[16]. This passive example detection or self-reporting of patients in the integrated leprosy-control program results in increased hidden and undiagnosed leprosy cases in the community, leading to more deformities and inability [17].

While studies in Ethiopia revealed owned leprosy pockets [18], the extent of hidden leprosy cases is rarely addressed [ix]. Therefore, this report adamant the magnitude of subconscious and undiagnosed leprosy using house-to-house visits as a tool for active case detection and to evaluate the household contacts of leprosy in selected leprosy owned districts in eastern Ethiopia in 2019.

Methods

Ethical consideration

This study was conducted according to the Helsinki Declaration and Ethiopian inquiry regulations. The Institutional Health Research Ethics Review Committee (IHRERC) of the College of Health and Medical Sciences, Haramaya Academy, Federal democratic republic of ethiopia (ref no: IHRERC/152/2018) and the Armauer Hansen Research Institute Ethics Committee (ref no: P002/18 AHRI/ERC) approved the protocol. The coordinator informed all participants in advance nigh the purpose and fourth dimension of the survey. Participants were given data on the objectives of the study, and informed consent was obtained in writing or past thumbprint. For those participants below 18 years of age, informed consent was obtained from a parent or legal guardian. To minimize the stigma, privacy was a priority during the examination of written report participants. Participants participated voluntarily and withdraw from the study at whatever time without any consequences. Anonymity was ensured past only having participant identification numbers included during data collection.

Report setting, design and flow

A community-based observational study was conducted in six leprosy owned villages in the Fedis District betwixt v July and xxx October 2019. Fedis is ane of the loftier leprosy endemic districts located in E Hararghe Zone, Oromia Regional State, Eastern Ethiopia. It is located at 534 km East of Addis Ababa and 24km to the southward of Harar (Fig 1).The district contains 19 rural and 2 urban villages with a total population estimated to be 133,382 persons. According to the zonal health office study, 57 and 47 new leprosy cases were receiving treatment in 2017 and 2018, resulting in a prevalence of three.5 to four.3 per 10,000 population (E Hararghe Zonal Health office, 2017 and 2018) (Zonal TB/Leprosy focal person communication).

Study population, and sampling

Since leprosy occurs in clusters, one large sample from a single area would non have been a reliable estimate of leprosy. Estimating the illness burden by conventional sampling procedure is difficult due to the big sample size requirement. Therefore, inverse sampling procedure was used [xix,twenty]. Fedis District was selected among 12 loftier leprosy endemic districts in the East Hararghe Zone. From the Commune, six villages with a leprosy endemicity brunt, with a total population of 35,673, were included randomly. All suspected cases and consenting individuals were screened through firm-to-house visits and consecutively enrolled for leprosy diagnosis. Report criteria excluded those on multi-drug therapy at the initiation of the study and a person who lived for less than 6 months in the selected villages.

Data collection procedure and tools

Survey.

Total village surveys of the selected villages were conducted, including all household members. Twelve trained health extension workers (HEWs) conducted the house-to-house visits to identify leprosy suspects. Using checklists, which was adopted from the national guideline, HEWs identified suspects past showing color photos of leprosy cases and asking if any household members had like symptoms. Suspects were referred to the nearby health facility and examined past leprosy experts from Armauer Hansen Research Constitute and the research team (researchers, health officers, and HEWs).

Physical examination.

All individuals suspected of having leprosy underwent a standardized concrete examination, as recommended by WHO and the national guidelines [21]. Briefly, the concrete examination focused on examination of the skin from caput to toe, including the front and dorsum sides, the presence of pare lesions (patches or nodules), loss of sensation over the peel lesions (patches) using a "wisp of cotton wool", and the number of skin lesions counted, if any. Palpation of the nerves was checked for cord enlargement and/or tenderness, and exam of eyes, hands and anxiety for any disabilities[22].

Bacteriological examination.

According to the national guidelines, the slit skin smear examination was performed for questionable cases to confirm the diagnosis; and was also used for leprosy classification. One slide, with smears taken from two sites (ear lobes and active lesion), was collected for examination and evaluation for M. leprae (acid-fast bacilli)[16]. Accordingly, the principal investigators obtained peel smears for bacteriological examination. Briefly, slit-skin smears were taken from ear lobes and skin lesions from 43 study participants. The slit-skin smears fabricated on the slide were stained by the Ziehl-Neelsen technique, using i% carbol fuchsin, ane% acid-booze and 0.25% methyl blueish. Nether oil immersion objective, red acid-fast bacilli were observed, bundled singly or in groups (cigar-like bundles), and bound together by a lipid-like substance, forming glia. The criteria used for diagnosis and nomenclature were based on the local leprosy control program and followed WHO guidelines as either paucibacillary (PB) or multibacillary (MB) type[21].

After confirmation of the leprosy diagnosis, the leprosy experts determined the caste of disability and initiated multi-drug therapy. The household contacts were so scheduled for screening by the research squad. Leprosy experts or dermatologists then examined the household contacts. Suspects with other pare diseases were linked to the nearby wellness center.

Questionnaire.

Structured questionnaires were administered to suspected cases and household contacts to obtain information on demographic characteristics and clinical history. Data related to leprosy diagnosis was obtained, including WHO classification of leprosy, disability grade, the clinical profile of individuals including BCG scar, contact history of leprosy, and whatsoever previous history of leprosy was documented.

Quality control.

Health extension workers were trained in the clinical examination for leprosy diagnosis and how to refer suspected cases to the nearby health center for further investigation by leprosy experts. HEWs conducted an interview in the local linguistic communication (Afan Oromo) and checklists were completed by face-to-face interviews for recruitment.

Study variables

The event variable was the magnitude of the hidden leprosy case. The independent variables include age, sex activity, occupation, residence, educational status, marital condition, BCG scar, and contact history of a patient with leprosy.

Operational definition

Suspect is an private who presented with pale or cherry-red patches (pare patch with discoloration) on the pare, painless swelling or lumps in the confront and earlobes, loss of, or decreased sensation on the skin, numbness or tingling of the hands and/or anxiety, weakness of eyelids, hands or feet, painful and/or tender nerves, burning sensation in the pare or painless wounds or burns on the hands or anxiety [16].

A leprosy example is a person with one of the cardinal signs of leprosy, and who requires chemotherapy. The fundamental signs of leprosy are I of the following: hypo-pigmented skin lesion with definite loss of sensation, thickened (enlarged) peripheral nerve with or without tenderness, and/or the presence of acid-fast bacilli in a slit-skin smear [xvi].

The PB type is a patient who is pare smear negative and/or the number of skin lesions is 1–five without demonstrated presence of bacilli in the smear [23].

The MB type is a patient who is skin smear positive and/or the number of skin lesions is more than five, with demonstrated presence of bacilli in the smear, irrespective of the number of skin lesions [23].

Physical disability in leprosy is divers past the WHO in three categories [24]: Form 0: the absence of inability (no anesthesia) and no visible damage or deformities of eyes, hands and feet; Grade I inability: the loss of protective sensibility in the eyes, hands or feet, but no visible impairment or deformities; and Grade 2: the presence of deformities or visible damage to the eyes (lagophthalmos and/or ectropion, trichiasis, corneal opacity, difficulty counting fingers at 6 meters), visible damage on hands or anxiety (hand with ulcerations and/or traumatic, resorption, hook, fallen hand, ulcers; anxiety with trophic and/or traumatic injuries, resorption, claw, human foot drop, ulcers, talocrural joint contracture) [25].

Household contact is a family member or any person that who lived under the aforementioned roof with the alphabetize case for more than half dozen months [26]. Co-prevalent leprosy is where the contacts diagnosed with leprosy at the first examination later on the alphabetize case were diagnosed [27].

Information management and statistical assay

Data were entered in Epi-Data version 3.1 and analyzed using STATA version 13.0. Descriptive statistics such as mean and percentages were used to draw the socio-demographic characteristics and the magnitude of hidden leprosy cases. Descriptive statistics such every bit mean and proportion and binary logistic regression analysis were used to appraise the association between the dependent and predictor variables. The significant association was declared at p-value < 0.05.

Results

Demographic characteristics of the written report participants

The HEW visited sixteen,107 individuals during a house-to-house survey and household contact (HHC) tracing. Of these, 268 were eligible, 262 (97.8%) of whom consented to participation and were enrolled in the study. Amid the volunteers who were evaluated for leprosy, 214 participants were identified equally suspects for leprosy during the firm-to-house visit, and 48 were household contacts of newly diagnosed cases. The mean (+ SD) age of the participants was 26.ix (±15.2) years. Most 45% of the participants were female and 62% were rural residents. About half (48%) of the participants had no formal didactics (Tabular array 1).

Prevalence of hidden leprosy

During active case-finding through the house-to-house visits, 214 suspects were evaluated both clinically and/or bacteriologically (Fig 2). 30 (14%) of the suspects had histories of contact with treated leprosy patients. Of the 214 suspects, xi leprosy cases were confirmed, giving a detection rate of 5.i% (95%, CI = 2%, 9%). Among the newly confirmed leprosy cases, ane patient had a prior history of leprosy (relapse case) and three cases had a contact history with a treated leprosy patient. The bulk (xc.9%) of cases were MB type leprosy, and two of them presented with grade 2 disability. Most (63.half-dozen%) of cases were farmers and 81.eight% were male.

Following the confirmation of 11 new cases, leprosy experts and dermatologists examined 48 HHCs through contact direction strategy. Among the 48 HHCs, four new leprosy cases (co-prevalent cases) were confirmed, giving an 8.three% detection rate (95%, CI = 2%, 19%). Among the co-prevalent cases, all of them were MB and two cases were nether 15 years of historic period.

By considering both suspects and HHCs evaluations, 15 participants were institute to be leprosy cases, giving a detection rate of v.7% (95%, CI: 3%, 9%). This yields a total population-based prevalence of hidden leprosy to be 9.three per 10,000 population. The majority 14(93.3%) of the newly diagnosed hidden cases were MB, and three cases demonstrated class Two disability. Among the newly diagnosed hidden cases, three were under 15 years of age and virtually one-fourth were female.

The extent of hidden leprosy was non statistically dissimilar based on their historic period category and contact history departure (p > 0.05). Furthermore, in the binary logistic regression analysis, the detection rate of subconscious leprosy cases was not statistically different based on their sex difference (P>0.05) (Tabular array ii).

Give-and-take

This study revealed the high prevalence of hidden leprosy in the general population. All co-prevalent patients were detected without having significant neuronal or visible physical damage at the initial stage of screening. Hidden leprosy was not associated with participants' demographic characteristics and contact histories. Therefore, the presence of pockets of high endemicity with a high prevalence rate of 9.3 per 10,000 population points to the arduous journey ahead for leprosy emptying in Ethiopia.

Ethiopia, with the introduction of multi-drug treatment (MDT), achieved the elimination target at the national level with a tape of 0.3 per 10,000 population in 2018 [22]. Our finding is higher than the national prevalence and that of Gambella regional country, which was two.4 per 10,000 in 2016 [22]. We used an agile instance detection strategy, compared to the in a higher place-mentioned lower estimates, which used passive case detection. However, the national leprosy control plan recommended the voluntary cocky-reporting (passive case detection) strategy. Moreover, the higher prevalence is evidence for the poor functioning of passive case detection compared with active case findings [28] and active case finding is an important epidemiological tool to minimize hidden leprosy cases [fifteen].

In this study all co-prevalent patients amidst HHCs were detected without having a significant neuronal or visible concrete damage at the initial stage of screening. This is an indication of the feasibility and contribution of active case-finding programs to promote early example detection past tracking HHCs [thirteen,29]. We found that one in five cases presented with form II disability on diagnosis, showing a prolonged delay in health-seeking. This is in harmony with the research conducted in Addis Ababa, where the proportion of grade 2 disability among new leprosy cases was 23.7% [30]. This finding is higher than the national report of 13.6% in 2016 [22]. The higher proportion of course II inability in the current report supports the late instance presentation and ongoing manual of leprosy [26,31]. It besides reflects inadequate monitoring in the national leprosy command plan [13] and the ongoing transmission of leprosy has not been interrupted [26]. Unfavorable attitude toward leprosy among the community in the same report setting [32] contributes to late presentation [33].

The proportion of childhood prevalence (20%) in this study is college than the national prevalence (xi.seven%) and that of Oromia regional state (13.3%) [22]. The presence of childhood leprosy amid new cases suggested the existence of the agile source of infection [34] and loftier ongoing transmission of the disease in the community [22]. The college proportion of childhood leprosy also a late performance indicator of the national leprosy control program [35].

This study revealed that subconscious leprosy is non significantly associated with participants' contact history with leprosy and their sex activity difference. Similar findings have been reported in other countries [15,36]. All study participants resided in shared vulnerable areas with high leprosy endemicity villages and the same environmental exposure condition [37,38]. Besides, more than half of the community in Fedis District was nutrient insecure [39]. Food shortage is shown as an of import poverty-related predictor of the clinical manifestation of leprosy and the greatest hazard [forty]. Therefore, they have the greatest chance of leprosy [41]. Hence, a higher prevalence of leprosy is expected in this district. Besides, the unfavorable mental attitude in the full general community in Fedis Commune and the stigma favors the hiding of patients from the diagnosis, irrespective of their sexual practice and contact history [32,42].

Strength and limitation of the study

This community-based active survey evidences the hidden leprosy cases that were missed by passive case detection in an endemic-leprosy setting. This study discovers leprosy patients who didn't seek health care before the inclusion. These leprosy patients are hidden inside the full general population and run a risk for themselves and others. All examinations of suspects were done in accordance with the national guidelines for leprosy diagnosis. Experienced leprosy experts and dermatologists performed clinical examinations. Learning from the successes of other disease prevention and improved health service utilization or health-intendance seeking through the deployment of wellness extension plan in Ethiopia[43–45], we used the trained health extension workers as data collectors to discover hidden leprosy. Using the existing health extension programs in a context of limited resources is more workable and provides more reliable data.

The inclusion of suspects was based on questioning individuals co-ordinate to the leprosy symptoms; individuals cannot recognize painless symptoms or do not written report to the HEW during the firm-to-business firm visits due to fear of stigma [33,46](selection bias). However, the colored picture used during the interview helped in recognizing symptoms.

Conclusions and recommendations

Conclusions

The overall prevalence of hidden leprosy is higher than the national and regional figures. An active finding and tracing of HHC in regions where leprosy is highly prevalent, like Fedis District, is an important strategy to promote early on diagnosis, minimize hidden leprosy and preclude astringent outcomes. The prevalence of hidden leprosy was not significantly unlike based on the contact history and demographic characteristics of the participants.

Recommendations

An outreach activity of agile case-finding targeting all age and sex grouping populations in leprosy pocket areas is crucial to stop leprosy and its complications.

It is important to develop a framework that incorporates leprosy instance-finding and HHC tracing strategies in the implementation of the health extension program.

Further studies considering larger sample size and different study blueprint demand to be undertaken to identify potential factors associated with hidden leprosy.

Acknowledgments

The authors would like to acknowledge the study participants, the district health office and data collectors for Haramaya University and AHRI their support in the report. Our bang-up appreciation likewise goes to project supervisors and colleagues for their back up.

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Source: https://journals.plos.org/plosntds/article?id=10.1371%2Fjournal.pntd.0009640

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