Josafá Gonçalves Barreto

Spatial analysis spotlighting early childhood leprosy transmission in a hyperendemic municipality of the Brazilian Amazon region.

Background More than 200,000 new cases of leprosy were reported by 105 countries in 2011. The disease is a public health problem in Brazil, particularly within high-burden pockets in the Amazon region where leprosy is hyperendemic among children. Methodology We applied geographic information systems and spatial analysis to determine the spatio-temporal pattern of leprosy cases in a hyperendemic municipality of the Brazilian Amazon region (Castanhal). Moreover, we performed active surveillance to collect clinical, epidemiological and serological data of the household contacts of people affected by leprosy and school children in the general population. The occurrence of subclinical infection and overt disease among the evaluated individuals was correlated with the spatio-temporal pattern of leprosy. Principal Findings The pattern of leprosy cases showed significant spatio-temporal heterogeneity (p<0.01). Considering 499 mapped cases, we found spatial clusters of high and low detection rates and spatial autocorrelation of individual cases at fine spatio-temporal scales. The relative risk of contracting leprosy in one specific cluster with a high detection rate is almost four times the risk in the areas of low detection rate (RR = 3.86; 95% CI = 2.26–6.59; p<0.0001). Eight new cases were detected among 302 evaluated household contacts: two living in areas of clusters of high detection rate and six in hyperendemic census tracts. Of 188 examined students, 134 (71.3%) lived in hyperendemic areas, 120 (63.8%) were dwelling less than 100 meters of at least one reported leprosy case, 125 (66.5%) showed immunological evidence (positive anti-PGL-I IgM titer) of subclinical infection, and 9 (4.8%) were diagnosed with leprosy (8 within 200 meters of a case living in the same area). Conclusions/Significance Spatial analysis provided a better understanding of the high rate of early childhood leprosy transmission in this region. These findings can be applied to guide leprosy control programs to target intervention to high risk areas.

High rates of undiagnosed leprosy and subclinical infection amongst school children in the Amazon Region

Leprosy in children is correlated with community-level factors, including the recent presence of disease and active foci of transmission in the community. We performed clinical and serological examinations of 1,592 randomly selected school children (SC) in a cross-sectional study of eight hyperendemic municipalities in the Brazilian Amazon Region. Sixty-three (4%) SC, with a mean age of 13.3 years (standard deviation = 2.6), were diagnosed with leprosy and 777 (48.8%) were seropositive for anti-phenolic glycolipid-I (PGL-I). Additionally, we evaluated 256 house-hold contacts (HHCs) of the students diagnosed with leprosy; 24 (9.4%) HHC were also diagnosed with leprosy and 107 (41.8%) were seropositive. The seroprevalence of anti-PGL-I was significantly higher amongst girls, students from urban areas and students from public schools (p < 0.0001). Forty-five (71.4%) new cases detected amongst SC were classified as paucibacillary and 59 (93.6%) patients did not demonstrate any degree of physical disability at diagnosis. The results of this study suggest that there is a high rate of undiagnosed leprosy and subclinical infection amongst children in the Amazon Region. The advantages of school surveys in hyperendemic areas include identifying leprosy patients at an early stage when they show no physical disabilities, preventing the spread of the infection in the community and breaking the chain of transmission.

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

BackgroundMycobacterium 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.MethodsClinic-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).ResultsNinety-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.ConclusionsUlcers 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 RegistrationThe trial was registered at ClinicalTrials.gov as NCT00860717.

What do we actually know about leprosy worldwide

778 www.thelancet.com/infection Vol 16 July 2016 with leprosy varies from 1·2% to 39·8% (or why grade 2 disability ranges from 0·0% to 28·0%) in different, but all equally poor, countries? The answers will only be possible when we understand that absence of diagnosis of leprosy is not the same as the absence of leprosy. The elimination target has become the mantra everywhere, but it is now meaningless. Although the zero-transmission strategy is highly desirable, comprehension and acknowledgment of the real worldwide leprosy situation is imperative fi rst.

High Anti–Phenolic Glycolipid-I IgM Titers and Hidden Leprosy Cases, Amazon Region

To the Editor: Leprosy remains a serious public health issue. Although the World Health Organization elimination target was achieved in 2000, with a prevalence of <1 case/10,000 persons, despite progress since introduction of multidrug therapy (1), large pockets of poverty remain in which the disease is hyperendemic and underdiagnosed. In fact, in highly disease-endemic areas, the prevalence of previously undiagnosed leprosy cases in the general population has been reported to be 6× higher than the registered prevalence (2). Most leprosy patients are in India and Brazil. In Brazil, new cases are concentrated in the Northeast, Midwest, and Amazon regions (from state capitals to the inner counties). Access to the health system is poor in these regions because of severe inequalities in the public health system of Brazil (3), A total of 34,894 new cases were registered in Brazil during 2010 (4), corresponding to an incidence rate of 18.22 cases per 100,000 population. Para State accounted for 10.2% of cases (3,562 cases), an incidence rate of 46.93 per 100,000 population. When only children <15 years of age were considered, Para registered 389 new cases of leprosy in 2010, representing 10.9% of all cases, an incidence rate of 16.52 per 100,000 population. In Oriximina, a county with 62,794 inhabitants in northwestern Para, ≈800 km from Belem, Para’s capital, a mean of 13.8 cases per year were registered for the past 5 years. In 2010, in Oriximina, we collected plasma samples from 138 students 8–18 years of age, from 35 leprosy patients who received a diagnosis during 2004–2009, and from 126 contacts of these patients (Federal University of Para Research Ethics Committee protocol no. 197/07). We tested all of these samples for anti–phenolic glycolipid-I (PGL-I) IgM; 42% of students, 54.3% of case-patients, and 45% of case-patient contacts were seropositive. In addition to collecting samples, we clinically examined the leprosy patients and their contacts, among whom we identified 3 new leprosy cases. We did not examine students at that time. Contacts were persons from the same household or neighborhood whom the index case-patient described as a person with whom he or she had a close relationship. Leprosy cases were diagnosed in the field on the basis of clinical signs, loss of sensation on the skin lesions, and presence of enlarged nerves. For operational reasons, skin smears were not performed. All cases were diagnosed by 2 leprologists. We used the Ridley-Jopling classification, associated with the indeterminate clinical type, as defined by the Madrid classification. The ELISA cutoff for positive results was arbitrarily established as an optical density of 0.295 based on the average plus 3× the SD of the test results from 14 healthy persons from the Amazon region (5). Because studies of the seroprevalence among contacts have reported a proportion of seropositive persons ranging from ≈1.9% to 18.4% (6), we returned to Oriximina 16 months after the first visit. We examined 2 groups of students and their contacts; 1 group was positive for anti–PGL-I, and the other group was negative for anti–PGL-I. We visited 44 households in 1 week. From the 35 leprosy patients encountered during the first visit, we selected 25 households to survey (14 with an anti–PGL-I–positive contact in the household and 11 without), and among students with results of anti–PGL-I serology, we selected 19 households (11 positive with an anti–PGL-I–positive contact in the household and 8 without). During our visits to all of these households, we examined 222 persons (Table). Table New leprosy cases detected among selected households, Oriximina, Para State, Brazilian Amazon, 2010 When we arrived in Oriximina, only 2 cases had been registered in the national notifiable diseases information system. By using our approach, 23 new cases were found after we investigated households that had a person positive for anti–PGL-I (15 multibacillary, 8 paucibacillary); we found only 7 new cases in households where residents were negative for anti–PGL-I (4 multibacillary, 3 paucibacillary) (Table). For comparison, during the last traditional leprosy campaign in Oriximina in 2008, eight new cases were detected. Furthermore, by using our strategy, the local public health service detected 9 additional new cases during the 4 months after our departure from Oriximina. These data emphasize that contact examination is crucial for identifying new cases (7) and that such investigation must be conducted periodically. Our data also indicate that subclinical infections are highly prevalent among public school students in the Amazon region and that identifying students with positive anti–PGL-I test results can lead to discovery of new leprosy cases among students’ household contacts.

Spatial and temporal epidemiology of Mycobacterium leprae infection among leprosy patients and household contacts of an endemic region in Southeast Brazil

BACKGROUND Leprosy is a chronic infectious disease that remains a public health problem in low- and middle-income countries. Household contacts of leprosy patients (HHCs) have increased risk of developing disease and are important links in the chain of transmission of Mycobacterium leprae. Based on epidemiological and operational factors, the global elimination strategy depends on the geographic stratification of endemic areas to intensify control activities. The purpose of the study was to integrate epidemiological indicators and serology into the spatial and temporal analysis of M. leprae infection, in order to understanding of the dynamics of transmission, essential information for the control of leprosy. METHODOLOGY Using location-based technologies and epidemiological data obtained from leprosy cases (N=371) and HHCs (N=53), during a 11year period (2004-2014), we explored the spatial and temporal distribution of diagnosed cases: stratified according their disease manifestation; and of subclinical infection among HHCs: determined by serology (anti-PGL-I ELISA and anti-NDO-LID rapid lateral-flow test); in order to assess the distribution pattern of the disease and the areas of greatest risk of illness, in a highly endemic municipality (Ituiutaba, MG) in the southeast region of Brazil. RESULTS Seropositivity among HHCs was: 17% (9/53) for anti-PGL-I ELISA; and 42% for the NDO-LID rapid lateral-flow test. Forty-nine percent of the contacts were seropositive to at least one of the immunological tests. DISCUSSION We observed substantial spatial heterogeneity of cases throughout the urban perimeter. Even so, four main clusters of patients and three main clusters of subclinical infection were identified. CONCLUSIONS Spatio-temporal epidemiology associated to serological assessment can identify high-risk areas imbedded within the overall epidemic municipality, to prioritize active search of new cases as well support prevention strategies in these locations of greater disease burden and transmission. Such techniques should become increasingly useful and important in future action planning of health interventions, as decisions must be made to effectively allocate limited resources.

Evidence of hidden leprosy in a supposedly low endemic area of Brazil

OBJECTIVES Show that hidden endemic leprosy exists in a municipality of inner São Paulo state (Brazil) with active surveillance actions based on clinical and immunological evaluations. METHODS The study sample was composed by people randomly selected by a dermatologist during medical care in the public emergency department and by active surveillance carried out during two days at a mobile clinic. All subjects received a dermato-neurological examination and blood sampling to determine anti-PGL-I antibody titers by enzyme-linked immunosorbent assay (ELISA). RESULTS From July to December 2015, 24 new cases of leprosy were diagnosed; all were classified as multibacillary (MB) leprosy, one with severe Lucios phenomenon. Seventeen (75%) were found with grade-1 or 2 disability at the moment of diagnosis. Anti-PGL-I titer was positive in 31/133 (23.3%) individuals, only 6/24 (25%) were positive in newly diagnosed leprosy cases. CONCLUSIONS During the last ten years before this study, the average new case detection rate (NCDR) in this town was 2.62/100,000 population. After our work, the NCDR was raised to 42.8/100,000. These results indicate a very high number of hidden leprosy cases in this supposedly low endemic area of Brazil.

Leonine Facies: Lepromatous Leprosy

A 57-year-old man presented with a 7-year history of diffuse skin infiltration associated with sensory loss in his left hand. His face had multiple nodular lesions that coalesced into plaques, especially on the forehead, ears, nose, and lips.

Evidence of zoonotic leprosy in Pará, Brazilian Amazon, and risks associated with human contact or consumption of armadillos

Mycobacterium leprae (M. leprae) is a human pathogen and the causative agent for leprosy, a chronic disease characterized by lesions of the skin and peripheral nerve damage. Zoonotic transmission of M. leprae to humans by nine-banded armadillos (Dasypus novemcinctus) has been shown to occur in the southern United States, mainly in Texas, Louisiana, and Florida. Nine-banded armadillos are also common in South America, and residents living in some areas in Brazil hunt and kill armadillos as a dietary source of protein. This study examines the extent of M. leprae infection in wild armadillos and whether these New World mammals may be a natural reservoir for leprosy transmission in Brazil, similar to the situation in the southern states of the U.S. The presence of the M. leprae-specific repetitive sequence RLEP was detected by PCR amplification in purified DNA extracted from armadillo spleen and liver tissue samples. A positive RLEP signal was confirmed in 62% of the armadillos (10/16), indicating high rates of infection with M. leprae. Immunohistochemistry of sections of infected armadillo spleens revealed mycobacterial DNA and cell wall constituents in situ detected by SYBR Gold and auramine/rhodamine staining techniques, respectively. The M. leprae-specific antigen, phenolic glycolipid I (PGL-I) was detected in spleen sections using a rabbit polyclonal antibody specific for PGL-I. Anti-PGL-I titers were assessed by ELISA in sera from 146 inhabitants of Belterra, a hyperendemic city located in western Pará state in Brazil. A positive anti-PGL-I titer is a known biomarker for M. leprae infection in both humans and armadillos. Individuals who consumed armadillo meat most frequently (more than once per month) showed a significantly higher anti-PGL-I titer than those who did not eat or ate less frequently than once per month. Armadillos infected with M. leprae represent a potential environmental reservoir. Consequently, people who hunt, kill, or process or eat armadillo meat are at a higher risk for infection with M. leprae from these animals.

miRNome Expression Analysis Reveals New Players on Leprosy Immune Physiopathology

Leprosy remains as a public health problem and its physiopathology is still not fully understood. MicroRNAs (miRNA) are small RNA non-coding that can interfere with mRNA to regulate gene expression. A few studies using DNA chip microarrays have explored the expression of miRNA in leprosy patients using a predetermined set of genes as targets, providing interesting findings regarding the regulation of immune genes. However, using a predetermined set of genes restricted the possibility of finding new miRNAs that might be involved in different mechanisms of disease. Thus, we examined the miRNome of tuberculoid (TT) and lepromatous (LL) patients using both blood and lesional biopsies from classical leprosy patients (LP) who visited the Dr. Marcello Candia Reference Unit in Sanitary Dermatology in the State of Pará and compared them with healthy subjects. Using a set of tools to correlate significantly differentially expressed miRNAs with their gene targets, we identified possible interactions and networks of miRNAs that might be involved in leprosy immunophysiopathology. Using this approach, we showed that the leprosy miRNA profile in blood is distinct from that in lesional skin as well as that four main groups of genes are the targets of leprosy miRNA: (1) recognition and phagocytosis, with activation of immune effector cells, where the immunosuppressant profile of LL and immunoresponsive profile of TT are clearly affected by miRNA expression; (2) apoptosis, with supportive data for an antiapoptotic leprosy profile based on BCL2, MCL1, and CASP8 expression; (3) Schwann cells (SCs), demyelination and epithelial–mesenchymal transition (EMT), supporting a role for different developmental or differentiation gene families, such as Sox, Zeb, and Hox; and (4) loss of sensation and neuropathic pain, revealing that RHOA, ROCK1, SIGMAR1, and aquaporin-1 (AQP1) may be involved in the loss of sensation or leprosy pain, indicating possible new therapeutic targets. Additionally, AQP1 may also be involved in skin dryness and loss of elasticity, which are well known signs of leprosy but with unrecognized physiopathology. In sum, miRNA expression reveals new aspects of leprosy immunophysiopathology, especially on the regulation of the immune system, apoptosis, SC demyelination, EMT, and neuropathic pain.