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BACKGROUND: The high levels of recent transmission of leprosy worldwide demonstrate the necessity of epidemiologic surveillance to understand and control its dissemination. Brazil remains the second in number of cases around the world, indicating active transmission of Mycobacterium leprae (M. leprae) in the population. At this moment, there is a consensus that the bacillus is transmitted by inter-human contact, however, different serologic, molecular, and histopathological approaches indicate the existence of non-human transmission sources. METHODS AND RESULTS: The qPCR assay was used to amplify the molecular targets 16S RNAr and RLEP, in samples of liver, spleen, and ear of wild animals belonging to Didelphimorphia and Rodentia orders, in highly endemic areas of Mato Grosso, Brazil. The RLEP repetitive sequence was positive in 202 (89.0%) samples, with 96 (42.3%) of these also being positive for the 16S gene. Regarding the collection sites, it was observed that the animals were found in areas profoundly deforested, close to urban areas. CONCLUSIONS: Our results suggest that wild animals can play an important role in the maintenance of M. leprae in endemic regions with major anthropic action in Brazil. Therefore, integrating human, animal, and environmental health care with the One Health initiative is highly efficient for the development of effective strategies to contain and control leprosy in Brazil.

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Introdução: a hanseníase é uma doença causada pelo bacilo Mycobacterium leprae, que afeta a pele e o sistema nervoso periférico, apresentando alta endemicidade no Brasil. As representações sociais negativas sobre ela resultam da construção histórica baseada em crenças e medos. Uma das estratégias preconizadas pelo Ministério da Saúde para reduzir a carga de hanseníase é a educação em saúde, já que um dos obstáculos para a diminuição da incidência da doença é a falta de informação. Objetivo: este estudo tem como objetivo identificar o conhecimento dos pacientes de um ambulatório de dermatologia acerca da hanseníase. Metodologia: trata-se de um estudo observacional e transversal, que se desenvolveu por meio de um questionário com nove questões sobre hanseníase, elaborado pelos autores e aplicados em pacientes do ambulatório de dermatologia de um hospital público em Pernambuco. Resultados: quinhentas pessoas responderam ao questionário, sendo a maioria mulheres e pessoas com mais de 60 anos. Cerca de 92% já haviam ouvido falar sobre lepra/hanseníase, mas menos da metade sabia que se tratava da mesma doença. Além disso, apenas 50,4% tinham alguma informação sobre a doença, sendo a identificação da lesão cutânea a mais conhecida, enquanto a transmissão e o tratamento eram menos conhecidos. Conclusão: percebe-se, portanto, que medidas de educação em saúde visando melhorar o conhecimento acerca da transmissão e do tratamento são de grande importância, principalmente por parte de profissionais de saúde, educação e mídia. Além disso, mais estudos que evidenciem o conhecimento da população sobre a doença precisam ser realizados para que a falta de informação possa ser suprida pelos profissionais e, assim, o combate à hanseníase e ao preconceito associado a ela seja realizado de modo mais efetivo. (AU)

Introduction: Hansen's disease is caused by the bacillus Mycobacterium leprae, which affects the skin and peripheral nervous system. It is highly endemic in Brazil. Negative social representations about leprosy are the result of historical beliefs and fears. Health education is a recommended strategy by Brazil's Ministry of Health to reduce the burden of leprosy. Lack of health information is one of the obstacles to reducing the incidence of the disease. Objective: this study aims to identify the level of knowledge that the patients at a dermatology outpatient clinic have about leprosy. Methods: this is a cross-sectional observational study, that utilized a nine-question leprosy questionnaire and was administered to patients at a public hospital dermatology outpatient clinic in Pernambuco. Results: five hundred people answered the questionnaire. The majority of respondents were women over the age of 60. Approximately 92% of respondents were aware of leprosy/Hansen's disease, but less than half correctly identified it as the same disease. Furthermore, only 50.4% of respondents had any knowledge about the disease. The identification of skin lesions was the most well-known symptom, while transmission and treatment were less familiar. Conclusion: therefore, it is evident that health education measures aimed at improving knowledge about the transmission and treatment of leprosy are crucial, particularly among health, educators, and media professionals. Additionally, conducting more studies to assess the population's knowledge of the disease is necessary to address the lack of information and enable professionals to combat leprosy and prejudices more effectively. (AU)

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A hanseníase é uma doença infecto contagiosa causada pelo Mycobacterium leprae (bacilo de Hansen), manifestada por lesões na pele e comprometimento dos nervos periféricos, tendo as vias aéreas superiores como a principal via de eliminação do bacilo e a mais provável porta de entrada

Leprosy is a contagious infectious disease caused by Mycobacterium leprae (Hansen's bacillus), manifested by skin lesions and impairment of peripheral nerves, with the upper airways as the main route of elimination of the bacillus and the most likely gateway

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Introdução: o diagnóstico clínico da hanseníase em crianças é particularmente difícil. Relato de Caso: crianças gêmeas bivitelinas, com três anos de idade, eram contactantes de pai com hanseníase Virchowiana. Os dois pacientes têm lesões cutâneas bem definidas e irregulares, anteriormente tratadas como micoses e uma cicatriz de BCG. Foram confirmados positivos para Mycobacterium por análise histopatológica da pele. Discussão: especialmente, com menos de cinco anos, os diagnósticos de hanseníase são raros e difíceis porque simulam outras doenças. Esses diagnósticos são alarmes epidemiológicos para áreas endêmicas e mostram a importância dos sintomas em crianças e o rastreamento nos contactantes dos pacientes.

Introduction: the clinical diagnosis of leprosy in children is particularly difficult. Case Report: fraternal twins, three years old, were in contact with a father with Virchowian leprosy. Both patients have well-defined and irregular skin lesions previously treated as mycoses and a BCG scar. They were confirmed positive for Mycobacterium by histopathological analysis of the skin. Discussion:especially, with less than five years, leprosy diagnoses are rare and difficult because they simulate other diseases. These diagnoses are epidemiological alarms for endemic areas and show the importance of symptoms in children and tracking of patients' contacts.

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OBJECTIVES: To analyse and map the leprosy risk areas in the state of Alagoas, an endemic region in the Northeastern Brazil, between 2001 and 2019. METHODS: Ecological and time series study, using spatial analysis techniques. First, we analyse the epidemiological aspects of leprosy cases, using the data available in the Notifiable Diseases Information System; then, we used the segmented log-linear regression model to assess time trends. Spatial distribution was analysed by the Local Empirical Bayesian Estimator and by calculating the Global and Local Moran Index. Finally, spatiotemporal clusters were identified through scanning statistics, using the Kulldorf method of retrospective analysis. RESULTS: We observed that Alagoas showed an average new case detection rate of 14.43/100,000 inhabitants between 2001 and 2019, being classified as highly endemic. The area of highest risk was the 9th health region (state hinterland), with increasing time trend (Annual Percentage Change/APC = 7.2; p-value < 0.05). Several clusters of high risk of leprosy transmission were verified in Alagoas, including the state capital and hinterland municipalities. CONCLUSIONS: Our data indicate that active M. leprae transmission persists in Alagoas; that diagnosis is delayed and that there are high-risk areas, especially in inland municipalities.

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Resumen Objetivo: El contagio familiar de la enfermedad de Hansen es un hecho bien establecido; aunque la transmisibilidad es baja, los contactos intradomiciliarios de personas enfermas sin tratamiento son un grupo con alto riesgo. El objetivo del estudio fue identificar las características sociodemográficas, culturales y clínicas comunes en grupos familiares, con antecedente de enfermedad de Hansen, como insumo para mejorar el tratamiento de la lepra. Metodología: Se realizó un estudio cualitativo, empleando la técnica de entrevista en profundidad semiestructurada, basándose en una guía de entrevista elaborada, y tomando como referencia factores sociodemográficos, sociales y culturales relacionados con el diagnóstico y tratamiento. Se seleccionaron 25 personas adultas entre 23 y 88 años de edad, de ambos sexos atendidos por el sistema de salud público costarricense. Se utilizaron genogramas para identificar miembros de la familia con antecedentes de la enfermedad. Resultados: El estudio mostró que 12 participantes provenían de 3 grupos familiares; dos grupos con tres generaciones afectadas. Los participantes fueron diagnosticados en edades económicamente activas de vida. Además, realizan ocupaciones manuales, con niveles educativos bajos y de religión cristiana. Al momento de la entrevista conocían el antecedente familiar. La forma de presentación clínica en los tres grupos familiares fue Lepra lepromatosa. Se identificó un caso de lepra conyugal y una participante de 15 años de edad al diagnóstico. Conclusiones: El estudio identificó características sociodemográficas, culturales y clínicas comunes de grupos familiares, que evidenciaron la necesidad de fortalecer la vigilancia de contactos en familias con nuevos casos.

Abstract Aim: Leprosy transmission within family groups is a well-established fact. Although transmissibility is low, household contacts are high-risk population. The aim of the study was to identify common sociodemographic, cultural and clinical characteristics in family groups with history of Hansen's disease as an input to improve treatment. Methodology: A qualitative study was carried out, using in-depth semi-structured interview technique based on leprosy diagnosis and treatment in sociodemographic, social and cultural context. A total of 25 adults between 23 and 88 years of age included both sexes attended by Costa Rican public health care system were selected. Genograms were used to identify family history of disease. Results: The study shows that 12 participants came from 3 family groups; two of them with third affected generation. The participants were diagnosed in economically active periods of life, work in manual occupations, with low level of education and Christians. At the time of the interview, participants knew the family history. The clinical presentation form was lepromatouse leprosy. A conjugal leprosy and a 15-year-old participant at diagnosis were identified. Conclusions: The study identified common sociodemographic, cultural and clinical characteristics of family groups that demonstrate the need to strengthen contact surveillance efforts in families with new cases.

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Reduction in incidence has been associated with the introduction of novel approaches, like chemo/immune-prophylaxis. Incidence determined through follow-up cohort studies can evaluate the implementation of these innovative policies towards control and prevention. We have assessed the incidence in our contacts cohort over past 33 years, considering the effect of demographic and clinical variables. Survival analysis was used to estimate the risk of leprosy. A total of 9024 contacts were evaluated, of which 192 developed leprosy, resulting in an overall incidence of 1.4/1000 person-years. The multivariate analysis showed that the major risk factors were (i) contact from MB index cases and (ii) consanguinity (iii) intra household contact. Lower risk was detected for contacts with BCG scar who were revaccinated. There was a significant decrease in accumulated risk between the 2011-2019 period compared with 1987, probably linked to the improvement in laboratory tools to monitor contacts, thereby providing early diagnosis of contacts at intake and reduction of transmission. Our findings suggest that a combination of contact surveillance and tracing, adequate neurodermatological examination, and availability of molecular tools is highly effective in supporting early diagnosis, while a second dose of the BCG vaccination can exert extra protection.

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Understanding and quantifying the risk of Hansen's disease (HD) through zoonotic transmission of Mycobacterium leprae infection from wild armadillos is important because hunting, handling and consumption of these animals is widespread in communities where HD is endemic, posing a potential threat to the health of individuals and to HD elimination. We conducted a systematic review (PROSPERO CRD42019159891) of publications in MEDLINE, EMBASE, Global Health, Scopus, LILACS, Biblioteca Digital Brasileira de Teses e Dissertações, Catálogo de Teses e Dissertações de CAPES, and Biblioteca Virtual em Saúde up to 09/05/2020 using Mesh and text terms in English, Portuguese, Spanish and French. Random effects meta-analyses were performed including of subgroups by endemicity and type of exposure. Seven of the nine included studies were case-control, four from Brazil and three from the USA, comprising 1,124 cases and 2,023 controls in total. The other two studies, one from Brazil and one from Colombia, were cross-sectional. The overall summary estimate (odds ratio, OR) for the relative odds of HD comparing people who had direct contact with armadillos and/or had eaten armadillo meat with those who had not was OR = 2.60 (95% CI 1.78-3.80, p < .001) with a predictive interval of OR = 1.10-6.17. Summary odds ratios for specific exposures were as follows: indirect contact, OR = 1.39 (95% CI 1.02, 1.89) (p = .04); eating, OR = 2.29 (95% CI 1.13, 4.66) (p = .02); hunting, OR = 2.54 (95% CI 1.21, 5.33) (p = .01). Most of the included studies had moderate risk of bias. Crude estimates were reduced by up to 24% when adjusted for confounders (where reported). Direct contact with wild armadillos was strongly associated with an increased risk of HD, whilst evidence for an increased risk of HD from indirect contact was weaker. The fraction of HD in endemic countries attributable to zoonotic transmission from armadillos remains unknown, but the precautionary principle needs to be adopted to protect public health.

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O objetivo deste estudo foi analisar os determinantes da infecção pelo Mycobacterium leprae e do adoecimento por hanseníase em contatos de casos da doença, residentes na Microrregião de Almenara, Minas Gerais, Brasil, a fim de compor um modelo de predição da hanseníase em contatos inseridos em regiões endêmicas. Trata-se de uma coorte retrospectiva de contatos domiciliares de casos de hanseníasecom período de acompanhamento de 1999 a 2018. Foi realizada coleta de dados com entrevista, aplicação de questionário semiestruturado, contendo informações sociodemográficas e de saúde, coleta de amostras biológicas e exame dermatoneurológico. As amostras biológicas subsidiaram a avaliação de polimorfismos genéticos e reatividade aos testes sorológicos. A escolha das variáveis explicativas incluídas nas análises se fundamentou no modelo teórico dos determinantes da hanseníase em contatos, elaborado a partir da realização de revisão sistemática. A análise de associação utilizou modelo de regressão logística por meio do método de estimação Generalized Estimating Equations. A construção do modelo de predição envolveu análise exploratória dos dados e aplicação de algoritmos de aprendizagem de máquina. Os determinantes da infecção pelo M. leprae foram: a cor de pele negra e parda, a presença de genótipos contendo o polimorfismo rs8057341 no gene NOD2 (Nucleotide-binding Oligomerization Domain Containing 2) e o convívio com caso apresentando incapacidades físicas no diagnóstico. Os determinantes do adoecimento por hanseníase foram: consanguinidade com o caso índice e a continuidade do convívio em intradomicílio ou peridomicílio após o diagnóstico do caso. A idade, o contato domiciliar e peridomiciliar, o convívio com mais de um caso e a presença de incapacidades físicas no diagnóstico foram determinantes para o risco à infecção e ao adoecimento em contatos. O genótipo heterozigoto contendo o polimorfismo rs2430561 no gene IFNG (Interferon-gama) foi fator protetor para a infecção e adoecimento em contatos. Os algoritmos de aprendizagem supervisionada Naive Bayes com discretização das variáveis numéricas, J48 e Random Forest tiveram os melhores desempenhos nos conjuntos de dados avaliados. Os determinantes do processo de infecção e adoecimento por hanseníase foram capazes de compor modelos de predição com a acurácia e sensibilidade superiores a 90% e indicam que a vigilância de contatos pode ser aprimorada pela utilização destas tecnologias nos serviços de Atenção Primária à Saúde, principalmente, em áreas de alta endemicidade.

This study aimed to investigate the determinants of Mycobacterium leprae infection and illness due to leprosy in contacts of cases of the disease in the Microregion of Almenara, Minas Gerais, Brazil, to support the construction of a leprosy prediction model in contacts of patients from endemic regions. We conducted a retrospective cohort of household contacts of leprosy patients with a follow-up period from 1999 to 2018. The researchers performed interviews using a semi-structured questionnaire containing sociodemographic and health questions, biological samples collection, and dermatological examination. Biological samples supported the evaluation of genetic polymorphisms and reactivity to serological tests. The choice of the explanatory variables included in the analysis was based on the theoretical model of the determinants of leprosy in contacts, developed from a systematic review. The association analysis used a logistic regression model using the Generalized Estimating Equations estimation method. The construction of the prediction model involved exploratory data analysis and applied machine learning algorithms. The determinants of M. leprae infection were: black and mixed skin color, homozygous and heterozygous genotypes containing the rs8057341 polymorphism in the NOD2 gene (Nucleotide-binding Oligomerization Domain Containing 2), and living with a leprosy patient with disabilities at diagnosis. The determinants of illness due to leprosy in contacts were: consanguinity with the index case and living in the same household or yard after the diagnosis of the leprosy patient. Age, living in the same household or lot, with more than one leprosy patient that presented disabilities at the diagnosis were determinants for the risk of infection and illness in contacts. The heterozygous genotype that carried the rs2430561 polymorphism in the IFNG gene (Interferon-gamma) was a protective factor for M. leprae infection and leprosy in contacts of patients. The supervised learning algorithms Naive Bayes with the discretization of numerical variables, J48 and Random Forest had the best performances in the evaluated datasets. The determinants of the process of infection and illness due to leprosy were able to compose prediction models with accuracy and sensitivity higher than 90%. These results indicate that using these technologies in Primary Health Care services can improve contact surveillance, especially in highly endemic areas.

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