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The Impact of Leprosy Control

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The Impact of Leprosy Control The Impact of Leprosy Control Epidemiological and modelling studies Abraham Meima Publication of this thesis was financially supported by Netherlands Leprosy Relief and by the Department of Public Health, Erasmus MC, University Medical Center Rotterdam. The impact of leprosy control: epidemiological and modelling studies / Meima, Abraham Thesis Erasmus MC, University Medical Center Rotterdam – With summary in English and Dutch Cover: Design: Peter Vogelaar, Studio PV, Rotterdam, [email protected] Back: patient notification form, The National Leprosy Registry of Norway Text lay-out: Mireille Wolfers, Abraham Meima Printed by PrintPartners Ipskamp, Enschede ISBN 90-9017864-3 © Abraham Meima, 2004 No part of this thesis may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording or otherwise, without written permission from the author. The Impact of Leprosy Control Epidemiological and modelling studies De invloed van leprabestrijding Epidemiologische en modelmatige studies Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de Rector Magnificus Prof. dr. S.W.J. Lamberts en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op woensdag 28 april 2004 om 11.45 uur door Abraham Meima geboren te Vlissingen Promotiecommissie Promotor: Prof. dr. ir. J.D.F. Habbema Overige leden: Prof. dr. A. Hofman Prof. dr. W.C.S. Smith Prof. dr. H.A. Verbrugh Copromotor: Dr. ir. G.J. van Oortmarssen voor Sander Contents 1 Introduction 9 1.1 Leprosy 10, 1.2 Leprosy control 13, 1.3 Global situation 17, 1.4 Modelling approach 19, 1.5 Research questions and outline of the thesis 24, 1.6 References 25 2 Trends in leprosy case detection rates 29 2.1 Summary 30, 2.2 Introduction 31, 2.3 Materials and methods 31, 2.4 Results 32, 2.5 Discussion 40, 2.6 Acknowledgment 47, 2.7 References 47 3 Trends in leprosy case detection worldwide since 1985 51 3.1 Summary 52, 3.2 Introduction 53, 3.3 Material and methods 54, 3.4 Results 55, 3.5 Discussion 61, 3.6 Acknowledgement 63, 3.7 References 63, 3A Appendix 65 4 SIMLEP: a simulation model for leprosy transmission and control 67 4.1 Summary 68, 4.2 Introduction 69, 4.3 The model 70, 4.4 Example 76, 4.5 Discussion 83, 4.6 Acknowledgments 86, 4.7 References 86, 4A Mathematical appendix 88 5 Disappearance of leprosy from Norway: an exploration of critical 95 factors using an epidemiological modelling approach 5.1 Summary 96, 5.2 Keywords 96, 5.3 Introduction 97, 5.4 Material 98, 5.5 Methods 100, 5.6 Results 106, 5.7 Discussion 111, 5.8 Key messages 115, 5.9 Acknowledgment 115, 5.10 References 115 6 The future incidence of leprosy: a scenario analysis 117 6.1 Summary 118, 6.2 Keywords 118, 6.3 Introduction 119, 6.4 Methods 120, 6.5 Results 122, 6.6 Discussion 127, 6.7 Acknowledgements 130, 6.8 References 130, 6A Appendix 132, 6A.1 Model and parameter quantifications 132, 6A.2 Sensitivity analysis 137, 6A.3 Reference data for case detection rate 138, 6A.4 References 138 7 Factors associated with impairments in new leprosy patients: 141 the AMFES cohort 7.1 Summary 142, 7.2 Introduction 143, 7.3 Materials and methods 144, 7.4 Results 145, 7.5 Discussion 151, 7.6 Acknowledgements 157, 7.7 References 157 8 Dynamics of impairment during and after treatment: 159 the AMFES cohort 8.1 Summary 160, 8.2 Introduction 161, 8.3 Materials and methods 162, 8.4 Results 163, 8.5 Discussion 169, 8.6 Acknowledgements 171, 8.7 References 171 9 Discussion 173 9.1 Answering the research questions 174, 9.2 Impairment caused by leprosy: an exploration of the future 183, 9.3 Conclusions and recommendations 187, 9.4 References 188 Summary 189 Samenvatting 193 Dankwoord – Acknowledgements 199 Curriculum vitae (English) 201 Curriculum vitae (Nederlands) 202 Publications 203 1 Introduction CHAPTER 1 This thesis consists of studies addressing the impact of leprosy control activities on the occurrence of leprosy and its impairments. Assessing this impact is difficult because the epidemiology of leprosy is fraught with uncertainties. Knowledge of processes governing leprosy transmission is limited, and controlled studies enabling direct assessment of the impact of interventions on transmission have never been conducted. Nevertheless, decisions regarding the extent and organisation of leprosy control programmes need to be made. This applies in particular to the present era, which has witnessed drastic epidemiological improvements in some developing countries, but no change in others. This introductory chapter provides a background to the studies presented in Chapters 2-8. First, essential knowledge of leprosy infection, disease and its consequences, and transmission is summarised (1.1). Next, the history of leprosy control and available control options are described briefly (1.2). Section 1.3 summarises patterns in the global occurrence of leprosy and related health problems from 1985 onwards. Section 1.4 introduces our epidemiological modelling approach for investigating the potential impact of leprosy control, and summarises earlier modelling work. Finally, the research questions of this thesis and outlines of the chapters are given (1.5). 1.1 Leprosy Leprosy is a chronic infectious disease which affects the peripheral nerves and the skin. It is often referred to as ‘the oldest disease known to man’ (1). The earliest written records describing leprosy come from India and date back to about 600 BC. The earliest remains of people confirmed to be affected with leprosy stem from Egyptian excavations which disclosed leprous skulls buried in the second century BC. Infection and disease Leprosy is caused by the bacillus Mycobacterium leprae. This bacillus was one of the first agents to be linked to an infectious disease. M. leprae was discovered in 1873 by Hansen in a Norwegian leprosy research hospital (2). Despite this early discovery, leprosy is even today a disease which is not well understood. The inability to culture M. leprae is an important reason. Establishing leprosy infection is difficult. A recent study which employed serological testing indicated leprosy infection to be far more common than leprosy disease (3), which confirms suggestions from the 1980s (4, 5). In recent years, considerable progress has been made in the development of diagnostic tools for leprosy infection, including skin and serological tests and molecular polymerase chain reaction tests (3). Still, it is not possible to predict who will develop leprosy disease and who will not. Genetic factors appear to influence resistance to leprosy infection and to development and expression of disease (6), but the importance of these factors is unclear. The duration of the incubation period of leprosy is also uncertain. Estimates were made for American and English war veterans who served in areas endemic for leprosy and later 10 INTRODUCTION developed leprosy disease (4). The estimated duration ranged from half a year to 21 years. It has been suggested that disease may not only develop after primary infection, but also from endogenous reactivation of dormant bacilli acquired earlier in life (5). In this thesis, leprosy disease refers to presence of signs that can be diagnosed through physical examination. Disease manifestations vary widely because cellular responses which constitute the body’s main defence against M. leprae vary strongly between individuals (4). Previously, the most common classification system used was the Ridley-Jopling system which recognises a spectrum with five groups and an ‘indeterminate’ class. Cellular immunity is strong at one end of the spectrum (polar tuberculoid leprosy, or TT), and absent at the other end (polar lepromatous leprosy, or LL). Skin and nerve lesions caused by leprosy have few bacilli at the tuberculoid, and many bacilli at the lepromatous side of the spectrum. Microscopic examination of skin smears for bacilli is often applied as an additional diagnostic procedure for classifying leprosy patients (i.e. those with signs of leprosy). A considerable proportion of tuberculoid patients may heal spontaneously. The three intermediate groups of the Ridley-Jopling system are referred to as borderline leprosy (BT, BB and BL). Movements of patients across the leprosy spectrum occur, and borderline leprosy is much less stable than the two polar forms of leprosy (TT and LL). Transmission The discovery of M. leprae in 1874 disproved the hereditary theory of leprosy. But even today the debate about the mode of transmission of M. leprae is not closed. Leprosy is considered to be transmitted almost exclusively within the human population. The two most common hypotheses for leprosy transmission are skin-to-skin contact and airborne transmission, with discharge of bacilli from the nasal mucosa of infectious individuals and entry of bacilli through the respiratory tract (6). Nowadays most leprologists favour the airborne hypothesis, which is supported by several observations: nasal excretion of leprosy bacilli is much more common than from any other part of the body in leprosy patients and untreated lepromatous patients excrete large numbers of bacilli from the nose (7). Also, occurrence of M. leprae DNA in the nose of healthy individuals has been shown to be widespread in leprosy endemic populations (3). The question of who is to what extent contributing to transmission remains unresolved. Traditionally, lepromatous (LL) patients were thought to be the main source of infection. But compared to the general population, the risk of developing leprosy is also considerably higher for household contacts of non-lepromatous patients (8-10). This may in part be due to common sources of infection outside the household. The idea that patients are the only source of infection is currently being challenged. Individuals incubating for leprosy disease could transmit leprosy, for there is no reason why the shedding of bacilli would start only with the onset of signs of leprosy disease, which involve nerve and skin.
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