| BackgroundLeprosy,an ancient chronic infectious disease caused by Mycobacterium leprae(ML),mainly affects the skin and peripheral nerves.The visible disabilities,or grade 2 disability(G2D),related to peripheral nerves involvement is the main cause of social,economic and psychological problems associated with leprosy.With an insidious onset and a variety of clinical manifestations,leprosy is easily ignored by sufferers and misdiagnosed by clinical doctors.The delay in diagnosis can result in continuous transmission of ML in the population and even the permanent disabilities of the patients.At present,the primary strategy of global leprosy control still relies on early detection and regular treatment of leprosy cases.The proportion of G2D among newly detected leprosy cases is one of the key indicators to evaluate the early detection of cases among different leprosy control programs.In 1994,Shandong Province had achieved the goal of elimination of leprosy by Chinese standard,i.e.less than 1 case per 100,000 population at county level.Mistaking "elimination" of leprosy for "eradication" of leprosy,some local governments dwindled their commitments towards leprosy control in the past two decades.Some of the vertical leprosy control programs had been abolished or integrated into general medical services.The funds for leprosy control were also cut down and leprosy control personnel were transferred to other positions or shunted away.At the end of 2007,the prevalence rate of leprosy in 7 counties in Shandong province once again exceeded the control standard of less than 1 case per 100,000 population.In 2008,the proportion of G2D among newly detected leprosy cases in Shandong province was as high as 50%,which was much higher than that of the global level and the national level.The early detection of leprosy cases needs to be urgently strengthened.Since the restoration of provincial funds for leprosy control in 2008,comprehensive measures aimed at improving early detection of leprosy cases had been carried out in Shandong Province.Objectives1.Analyze the epidemiological data of newly detected leprosy cases in Shandong Province from 2007 to 2017.2.To evaluate the effectiveness of comprehensive measures on early detection of leprosy cases.3.To provide information for future policies on the early detection of leprosy cases.MethodsThe subjects of this descriptive retrospective study were the newly detected leprosy cases diagnosed in Shandong Province from 2007 to 2017.To ensure the accuracy of the diagnosis,from 2007 on,all the suspected cases of leprosy were required to be referred to Shandong provincial institute of dermatology and venereology(SDPIDV)for further confirmation.For those seriously disabled or in poor health who failed to go to SDPIDV,leprosy professionals went to the county where the suspected cases lived for investigation.The diagnosis of leprosy was based on four diagnostic points:lesions with definite loss of sensation(anesthetic skin lesions);Enlarged peripheral nerves with relevant functional impairments;Positive bacteriological tests(either through skin slit smear,acid-fast staining on tissue sections,or real-time quantitative polymerase chain reaction(qPCR)for detection of specific DNA fragments of ML);finding pathological changes specific to leprosy.Diagnosis of leprosy can be made only if two or more of the four points were present.Two-type classification system proposed by World Health Organization(WHO)in 1988 was used and the patients were divided into multibacillary(MB)or paucibacillary(PB).Disability classification system of leprosy proposed by WHO in 1988 was used and patients with visible disabilities of hands and/or feet and/or severe visual impairment were classified as G2D.Delay in diagnosis was defined as the interval between the onset of the first symptom and the diagnosis of leprosy.Those born and brought up in other than Shandong Province were grouped as imported cases.A questionnaire including demographic information,health-seeking behavior information and disease-related information was put into use to collect relevant data of leprosy cases.Data collection was mainly conducted in SDPIDV and the time needed for each interview was about 30 minutes.SPSS 22.0 software was used for statistical analysis.Qualitative variables were expressed as frequency and percentage while quantitative variables were expressed as mean and standard deviation.Chi-square test or Fisher’s exact probability method was used to compare rates or percentages and trend Chi-square test was used to compare trends of rates or percentages.The t test was used to compare the differences of quantitative data.Multivariate Logistic regression was used to analyze the correlative factors of G2D in leprosy.ResultsFrom 2007 to 2017,232 new leprosy cases were detected in Shandong Province,of which 1 case did not participate in the interview due to mental reasons.Finally,the epidemiological data of 231 cases were analyzed.During the study period,the annual detection rate of leprosy cases in Shandong province decreased from 0.038/100,000 in 2007 to 0.013/100,000 in 2017.Leprosy cases were mainly distributed in former high epidemic areas.Of those 137 counties in the whole province,94(68.6%)had found leprosy cases during 2007-2017.In recent years,sporadic cases including both imported cases and autochthonous cases could often be seen in some low epidemic areas.The prevalence rate of leprosy in 7 counties had once exceeded the standard of less than 1 case per 100000 population.In another county,with a total of four leprosy cases had been detected in history,a fifth case was detected among the autochthonous population after a lack of new cases for more than 30 years.Of the 231 cases,191(82.7%)were autochthonous cases and 40(17.3%)were imported cases.The male-to-female ratio of new cases was 1.3:1.The proportion of imported cases in female cases was significantly higher than that of male cases(χ2=22.43,P<0.001).The mean age at diagnosis was 51.7(18-85)years old and the annual mean age at diagnosis showed a slight upward trend over the years.3 patients were younger than 15 years at onset and belonged to children cases.221(95.7%)were peasants or unskilled laborers,73 cases(31.6%)were illiterates.The proportion of illiterates in female cases(48.5%)was significantly higher than that in male cases(18.5%)(χ2=23.75,P<0.001).Most(31/40,77.5%)of the imported cases were female.The majority(28/31)of the female imported cases were housewives.Most of the imported male cases(8/9)were unskilled laborers.Regarding exposure to leprosy,47(20.3%)reported household contact,26(11.3%)had non-household contact and 158(68.4%)denied any contact with leprosy cases.The proportion of MB cases among the 231 cases was 79.3%and this proportion rose to 96.6%during 2013-2017.During 2007-2017,the annual proportion of MB cases showed an significant increasing trend(χ2=17.36,P<0.001).181(78.4%)were detected by skin clinics.The proportion of those detected by skin clinics among autochthonouscases(75.4%)was significantly lower than that of imported cases(92.5%)(χ2=5.71,P<0.05).Of the 212 cases with health seeking experiences,only 32(15.1%)were diagnosed as leprosy at first visit.The mean delay in presentation,medical service and diagnosis of the 231 cases was 30.1 months,34.3 months and 64.2 months respectively.Differences between autochthonous and imported cases and between male and female were not significant.There was no significant changing trend in the patient delay,medical service delay and delay in diagnosis over the years.92 cases(39.8%)presented with G2D at diagnosis.The proportion of G2D in new cases peaked in 2008(50%)and decreased year by year since then and remained at 25%or less during 2014-2017.The trend of annual proportion of G2D among new cases decreased significantly over the years(χ2=8.23,P<0.01).Among the G2D group and the non-G2D group,the mean patient delay was 46.4 months and 19.3 months respectively and the difference was statistically significant(t=-3.10,P<0.01);the mean delay in diagnosis was 89.8 months and 47.1 months respectively and the difference was statistically significant(t=-4.29,P<0.001);the proportion of those with a patient delay of more than 12 months was 48.9%and 28.5%respectively and the difference was statistically significant(χ2=9.77,P<0.01);the proportion of those with a total delay of more than 24 months was 81.5%and 50.4%respectively and the difference was statistically significant(χ2=23.00,P<0.001);the proportion of PB patients was 30.4%and 13.7%respectively and the difference was statistically significant(χ2=9.60,P<0.01);the proportion of those with known infectious sources was 39.1%and 26.6%respectively and the difference was statistically significant(χ2=4.01,P<0.05).66.3%and 86.3%were detected by skin clinics respectively and the difference was statistically significant(χ2=13.09,P<0.001).According to the results of the multivariate logistic regression analysis,with a total delay of more than 24 months(OR=5.28,95%CI=2.54-11.00),PB type(OR=3.48,95%CI=1.55-7.81)and detected by other than skin clinics(OR=2.13,95%CI=1.00-4.54)were still associated with the occurrence of G2D in leprosy cases.DiscussionThe rapid decline in the number of newly detected leprosy cases worldwide in the past two decades had raised great concerns among many researchers.The hypothesis that actual number of leprosy cases may be much higher than the number reported had been confirmed by active case-finding activities in some countries.Over the past 10 years,the number of newly detected leprosy cases had decreased gradually at global,national level and in Shandong province.With no counties exceeding the goal of leprosy elimination,high age at diagnosis and the increasing trend of the proportion of MB cases over the years all indicate that leprosy perhaps is dying out in Shandong province.The former high epidemic counties are still the areas where more new leprosy cases were found,and also the key areas for leprosy control activities in the future.Some former epidemic counties have seen a rebound of the epidemic.Cases latent in the mobile population further increased the difficulty of early detection of leprosy cases.In the foreseeable future,leprosy cases still can be seen.The government should continue to attach great importance to leprosy control programs Powerful and effective policies should be initiated and necessary and sufficient financial support should be provided for leprosy control activities.In post-elimination era,leprosy cases were characterized by long delay in diagnosis,high proportion of MB type and high proportion of G2D.The early detection of leprosy cases in Shandong province was effectively improved by comprehensive measures including health promotion program,personnel training,reward-offering,symptom surveillance and a powerful referral center,which was shown by significant decline of the proportion of G2D among new patients from 50%in 2008 to below 25%in 2014-2017.Innovative and active case finding methods was one of the identified key processes in implementing the global strategy.Monitoring of leprosy symptoms,changing skin-clinics from passive case-finding to active surveillance and from temporary intensified campaigns to routine monitoring,is a new kind of active case-finding activity.This method may play an important role in early detection of leprosy in the future,especially in post-elimination era and in low endemic areas.These comprehensive measures may also work in other provinces and other countries.At global level,the proportion of G2D among new leprosy cases is 5.8%(12,437/214,783)in 2016.As for Shandong,although the rate of newly detected leprosy cases with G2D had already been reduced to less than 1 per 100,000 population,with a G2D proportion of more than 20%,there is still room for improvement in early detection of leprosy cases.In this study,we found that with a total delay of more than 24 months,PB type,and detected by other than skin clinics were associated with the occurrence of G2D in leprosy patients.In order to further improve the early detection of leprosy cases in the future and prevent new patients from developing G2D,it is necessary to further shorten the delay in diagnosis and continue to give full play to the role of dermatologists in the early detection of leprosy cases.Social discrimination,unfamiliarity with or neglect of the early symptoms of leprosy are the main reasons for patient delay.The most important reason for the medical service delay was misdiagnosis of leprosy as other diseases.In order to shorten the delay in diagnosis,it is necessary through health education to make the public aware that leprosy is curable,that special prophylactic measures are not necessary and that it’s safe if leprosy patients lived and being treated in the community.Health education towards medical staff is not only conducive to the early detection of leprosy patients,but also can avoid the refusal or prevarication of leprosy patients.To give full play to the role of dermatologists in early detection of leprosy cases,they should be trained with knowledge and skill associated with early detection of leprosy cases.The dermatologists at both general health services and vertical leprosy control programs should be trained and their vigilance against leprosy should be enhanced.To encourage report of suspected cases of leprosy,some kind of incentive measures such as reward-offering also can be used.Population mobility can facilitate the spread of leprosy from endemic areas to non-endemic areas.Due to the low cost-effectiveness characteristics of the active case-finding activities,early diagnosis of imported cases is even more difficult and imported patients are more prone to developing G2D.To detect imported cases as early as possible,monitoring of floating population should be strengthened and special health education program should be considered by leprosy control managers,Clinicians should consider the possibility of leprosy in patients with unknown chronic skin diseases originated from areas with high prevalence of leprosy.Entry examinations or regular family examinations for imported populations should be initiated according to the occupation of imported cases.In order to do better in the treatment,management,contact tracing and epidemic investigation of imported cases,it is necessary for leprosy control programs in importing and exporting places to keep necessary communication and contact. |
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