Strategies for control and surveillance of leprosy contacts: integrative review

Kezia Cristina Batista dos Santos Rita da Graça Carvalhal Frazão Corrêa Isaura Letícia Tavares Palmeira Rolim Lívia Maia Pascoal Adriana Gomes Nogueira Ferreira About the authors

ABSTRACT

The objective of this research was to analyze the available scientific evidence on control and epidemiological surveillance of leprosy contacts. This is an integrative review guided by the question: what is the scientific production on control and epidemiological surveillance of leprosy contacts? Primary studies published in English, Portuguese, or Spanish in the PubMed, Lilacs, and Cinahl databases from 2008 to 2018, available in full, were included. The sample consisted of 19 studies. Three thematic categories were identified: risk factors for infection and illness among leprosy contacts, active surveillance of leprosy contacts, and new strategies for control and surveillance of leprosy contacts. The results showed studies focused on the prevention and control of leprosy among contacts, however, the evidence points to new strategies that may be incorporated into clinical practice aiming at the elimination of leprosy as a public health problem in the Country.

KEYWORDS
Leprosy; Epidemiological monitoring; Contact tracing

Introduction

Leprosy is an infectious, transmissible disease caused by Mycobacterium leprae, which manifests itself through dermatoneurological signs and symptoms. Predilection of the bacillus for peripheral nerves is responsible for neurological disorders that may result in physical disabilities and deformities11 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância das Doenças Transmissíveis. Diretrizes para vigilância, atenção e eliminação da Hanseníase como problema de saúde pública: manual técnico-operacional. Brasília, DF: Ministério da Saúde; 2016..

In Brazil, the classification of leprosy cases is based on that of Madrid (1953), which considers as clinical forms the Indeterminate (I), Tuberculoid (T), Dimorphic (D) and Virchowian (V). These, for treatment purposes, are grouped in Paucibacillary - PB (I and T) and Multibacillary - MB (D and V)22 Brasil. Ministério da Saúde, Secretaria de Políticas de Saúde, Departamento de Atenção Básica. Guia para o Controle da hanseníase. Brasília, DF: Ministério da Saúde; 2002.,33 World Health Organization. Guia para la Eliminación de la Lepra como Problema de Salud Pública. Geneva: WHO, LEP; 2000..

Transmission occurs directly, through the upper respiratory tract (mucous membranes and oropharynx), in which a sick person and in its MB forms infects other people by eliminating the bacillus in the external environment. The incubation period lasts from two to seven years44 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Boletim Epidemiológico - Hanseníase. Brasília, DF: Ministério da Saúde; 2018.. The most susceptible population includes the MB family case contacts, followed by extra domiciliary contacts and PB55 Schreuder PA, Noto S, Richardus JH. Epidemiologic trends of leprosy for the 21st century. Clin Dermatol. [internet]. 2016 [acesso em 2018 jun 2]; 34(1):24-31. Disponível em: http://www.sciencedirect.com/science/article/pii/S0738081X150.
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cases.

The magnitude and the high incapacitating power keep the disease as a public health problem in different countries, including Brazil, which, despite establishing strategies that favor its elimination, continues to present trends that are still far from control66 World Health Organization. Weekly epidemiological record. Geneva: WHO; 2017.. In 2016, there were 25,218 new cases reported in the Country, which is equivalent to a detection rate of 12.2/100 thousand inhabitants77 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Guia de vigilância em saúde. Brasília, DF: Ministério da Saúde. 2014.. In 2008, there was a general prevalence of 2.06 cases/10 thousand inhabitants, and in 2015, prevalence went down to 1.01 cases/10,000 inhabitants88 Assis LPF, Cozer AM, Amâncio VC, et al. Evaluation of epidemiological indicators for leprosy in Brazil, 2008 - 2015. Rev. Educ. Saúde [internet]. 2017 [acesso em 2018 jun 4]; 5(1):6-14. Disponível em: http://periodicos.unievangelica.edu.br/index.php/educacaoemsaude/article/view/2377/2034.
http://periodicos.unievangelica.edu.br/i...
. However, despite these efforts, these parameters still classify the Country in terms of high burden for the disease, being the second with the largest number of new cases registered in the world and the first in the Americas, only behind India44 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Boletim Epidemiológico - Hanseníase. Brasília, DF: Ministério da Saúde; 2018.,66 World Health Organization. Weekly epidemiological record. Geneva: WHO; 2017..

With the aim of reducing the leprosy burden at the global and local levels, it has been developed, by the World Health Organization (WHO), the Global Leprosy Strategy 2016-2020, to accelerate action towards a world without leprosy. The current strategy is focused, mainly, on countries that have not yet reached the elimination of leprosy as a public health problem at the subnational level and is based on three pillars: strengthening government control, coordination and partnership; combating leprosy and its complications; combating discrimination and promoting inclusion make up the third pillar99 Organização Mundial de Saúde. Estratégia Global para Hanseníase 2016-2020: acelerar a ação para um mundo sem lepra. Geneva: OMS; 2016..

To reach the leprosy control goal of the WHO and the Ministry of Health (MH), it is necessary to obtain a prevalence of less than 1 case/10 thousand inhabitants. Therefore, it is necessary to invest in effective actions for the early diagnosis and control of the disease11 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância das Doenças Transmissíveis. Diretrizes para vigilância, atenção e eliminação da Hanseníase como problema de saúde pública: manual técnico-operacional. Brasília, DF: Ministério da Saúde; 2016.,99 Organização Mundial de Saúde. Estratégia Global para Hanseníase 2016-2020: acelerar a ação para um mundo sem lepra. Geneva: OMS; 2016..

Contacts surveillance is considered one of the most effective measures for the diagnosis and control of leprosy, ensuring adequate coverage and quality77 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Guia de vigilância em saúde. Brasília, DF: Ministério da Saúde. 2014.,1010 Brasil. Ministério da Saúde. Portaria n° 3125, de 7 de outubro de 2010. Aprova as diretrizes para vigilância, atenção e controle da hanseníase. Diário Oficial da União. 15 Out 2010.,1111 Brasil. Ministério da Saúde. Plano integrado de ações estratégicas de eliminação da hanseníase, filariose, esquistossomose e oncocercose como problema de saúde pública, tracoma como causa de cegueira e controle das geohelmintíases: plano de ação 2011-2015. Brasília, DF: Ministério da Saúde; 2012.. Its purpose is the discovery of new cases among those living or who have lived, in a prolonged way, with the new case of leprosy diagnosed44 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Boletim Epidemiológico - Hanseníase. Brasília, DF: Ministério da Saúde; 2018.,1010 Brasil. Ministério da Saúde. Portaria n° 3125, de 7 de outubro de 2010. Aprova as diretrizes para vigilância, atenção e controle da hanseníase. Diário Oficial da União. 15 Out 2010..

In this context, the MH defines as household contact any person who lives or has lived with the leprosy patient, regardless of the operational classification and living time; and as social contact, any person who lives or has lived in family relationships or not, in a close and prolonged way, including neighbors, work and school colleagues, among others, who must also be investigated according to the level and type of coexistence11 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância das Doenças Transmissíveis. Diretrizes para vigilância, atenção e eliminação da Hanseníase como problema de saúde pública: manual técnico-operacional. Brasília, DF: Ministério da Saúde; 2016..

Thus, contact tracing not only results in the detection of additional cases, but also has indirect advantages, such as early diagnosis and reduced risk of transmission. For this reason, for each newly diagnosed case, it is essential that the contacts be examined, this way it will be possible to interrupt the chain of transmission1212 Pedrosa VL, Dias LC, Galban E, et al. Leprosy among schoolchildren in the Amazon region: a cross-sectional study of active search and possible source of infection by contact tracing. Plos negl. trop. dis. [internet]. 2018 [acesso em 2018 jun 2]; 12(2):e0006261. Disponível em: http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0006261.
http://journals.plos.org/plosntds/articl...
,1313 Hacker MA, Duppre NC, Nery JAC, et al. Characteristics of leprosy diagnosed through the surveillance of contacts: a comparison with index cases in Rio de Janeiro, 1987-2010. Mem. Inst. Oswaldo Cruz [internet]. 2012 [acesso em 2018 Jun 2]; 107:49-54. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0074-02762012000900009.
http://www.scielo.br/scielo.php?script=s...
.

In light of this, the following question has arisen: what is the scientific production on control and epidemiological surveillance of leprosy contacts? Thus, the objective was to analyze the available scientific evidence on control and epidemiological surveillance of leprosy contacts.

Methodology

It is an integrative review of the literature which included the following steps: identification of the research question; definition of the inclusion and exclusion criteria; categorization and assessment of studies, extraction and interpretation of results and synthesis of knowledge1414 Mendes K, Silveira R, Galvão C. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & contexto enferm. [internet]. 2008 [acesso em 2018 jun 4]; 17(4):758-64. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072008000400018.
http://www.scielo.br/scielo.php?script=s...
.

Data collection was carried out in April 2018. The PICO1515 Santos C, Pimenta C, Nobre M. The PICO strategy for the research question construction and evidence search. Rev. latinoam. enferm. [internet]. 2007 [acesso em 2018 jun 5]; 15(3):508-11. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692007000300023.
http://www.scielo.br/scielo.php?script=s...
acronym was used to elaborate the search strategies in the PubMed (National Library of Medicine and the National Institutes of Health), Lilacs (Latin American and Caribbean Health Sciences Literature) and Cinahl (Cumulative Index to Nursing and Allied Health Literature) database, as described in chart 1. These databases were chosen because they contain the main journals in the health and nursing area which deal with the subject of interest for the present study.

Chart 1
Search strategy used. São Luís (MA) Brazil, 2018

The descriptors and keywords used in the search were applied according to particularities of each database and obtained by consultation in the Health Sciences Descriptors (DeCS), Medical Subject Headings (MeSH) and Cinahl Titles. Combinations of terms were performed using Boolean operators ‘or’ and ‘and’, in which the first one was used to combine the descriptors and keywords common to each component of the PICO strategy, and the second one, to finalize the search strategy, a combination of the three terms was carried out: (P) and (I) and (Co). The date filter (2008 to 2018) was used for all searches. The descriptors were inserted in the English language, since all journals indexed in these databases present in their articles descriptors in English.

After the search stage, original articles were selected, from the review of the titles and abstracts, according to the following criteria for inclusion: 1) primary articles available in full; 2) in open online access; 3) in Portuguese, English or Spanish; 4) covering epidemiological surveillance of leprosy contacts; and 5) published in the period from 2008 to 2018.

Subsequently, the reading of complete texts was carried out, searching for the studies which answered to the question of research. Publications that: 1) addressed a topic other than that of interest in this work were excluded; 2) were duplicated; 3) secondary studies, letters, editorials, reports of experience, case studies, theses, dissertations and book chapters.

For the organization of the data, an instrument adapted from Ursi1616 Souza MT, Silva MD, Carvalho R. Integrative review: what is it? How to do it? Einstein (São Paulo) [internet]. 2010 [acesso em 2018 jun 10]; 8(1):102-106. Disponível em: http://www.scielo.br/pdf/eins/v8n1/pt_1679-4508-eins-8-1-0102.
http://www.scielo.br/pdf/eins/v8n1/pt_16...
was used containing the following items: bibliographic reference (title, authorship and year of publication), language, country of origin, database, research objectives, study design, main results, conclusions, limitations and level of evidence.

For the categorization of the Level of Evidence (LE), seven levels of classification were considered: level 1, systematic review or meta-analysis of controlled clinical trials; level 2, well-delineated randomized controlled clinical trial; level 3, controlled clinical trial without randomization; level 4, welldelineated cohort or case-control studies; level 5, systematic review of qualitative and descriptive studies; level 6, descriptive or qualitative studies; and level 7, opinion of authorities or experts1717 Melnyk BM, Fineout-Overholt E. Making the case for evidence-based practice. In: Melnyk BM, Fineout-Overholt E, organizadores. Evidence-based practice in nursing & healthcare. A guide to best practice. Philadelphia: Lippincot Williams & Wilkins. 2005. p. 3-24..

Evidences from a systematic review or meta-analysis and evidence originating from the opinion of authorities and/or expert committee reports were not classified, because they were excluded at the data collection stage. The results were analyzed and presented in a descriptive way.

The critical analysis of the selected articles was carried out independently by exploratory and analytical reading to evaluate the content of each study. For the treatment of the data, it was used the classification by thematic area, allowing a panoramic view, contemplating the main information and relevant points of the developed researches.

Results

The synthesis of the results obtained in the search stages of the articles is presented in figure 1. The articles included were listed from A1 to A19 for didactic purposes.

Figura 1
Estudos primários incluídos na revisão integrativa de acordo com as bases de dados. São Luís (MA) Brasil, 2018

Regarding the characterization of primary studies, 14 were developed in Brazil, 1 in China, 2 in Bangladesh, 1 in Colombia, and 1 multicenter which encompassed the following countries: India, Indonesia, Myanmar, Nepal, Sri Lanka, Tanzania, Brazil and Cambodia, with 11 surveys published in English; and 8, in Portuguese.

Related to the year of publication, the year 2008 stands out with four articles. As for LE, 16 articles covered analytical or descriptive observational studies (LE 6), 1 was a case-control study (LE 4) and 2 were randomized clinical trials (LE 2).

The primary studies were grouped into three categories of analysis, due to thematic similarity. In charts 2, 3 and 4, the characteristics of the primary studies included in the review are presented, according to each delimited category.

Chart 2
Characteristics of the studies presented in the category 'Risk factors for infection and illness among leprosy contacts'. São Luís (MA) Brazil, 2018
Chart 3
Characteristics of the studies presented in the category 'Active surveillance of leprosy contacts'. São Luís (MA) Brazil, 2018
Chart 4
Characteristics of studies presented in the category 'New strategies for control and surveillance of leprosy contacts'. São Luís, MA, Brazil, 2018

Risk factors for infection and illness among leprosy contacts

Of the seven studies classified in this category, all evidenced that the home contacts of patients with leprosy presented a higher risk of illness1818 Goulart IMB, Souza DOB, Marques CR, et al. Risk and Protective Factors for Leprosy Development Determined by Epidemiological Surveillance of Household Contacts. Clin Vaccine Immunol. [internet]. 2008 [acesso em 2018 jun 14]; 15(1):101-105. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223848/.
https://www.ncbi.nlm.nih.gov/pmc/article...

19 Dessunti EM, Soubhia Z, Alves E, et al. Hanseníase: o controle dos contatos no município de Londrina-PR em um período de dez anos. Rev. bras. enferm. [internet]. 2008 [acesso em 2018 jun 15]; 61(spe):689-693. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S003471672008000700006&lng=en.
http://www.scielo.br/scielo.php?script=s...

20 Durães SMB, Guedes LS, Cunha MD, et al. Estudo epidemiológico de 107 focos familiares de hanseníase no município de Duque de Caxias - Rio de Janeiro, Brasil. An. bras. dermatol. [internet]. 2010 [acesso em 2018 jun 15]; 85(3):339-345. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S036505962010000300007&lng=en.
http://www.scielo.br/scielo.php?script=s...

21 Sarno EN, Duarte NC, Vendas AM, et al. Exposição à hanseníase, infecção e doença: um estudo de vigi lância de 25 anos dos contatos de pacientes com hanseníase. Mem. Inst. Oswaldo Cruz [internet]. 2012 [acesso em 2018 jun 15]; 107(8):1054-1059. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0074-02762012000800015&lng=en.
http://www.scielo.br/scielo.php?script=s...

22 Lima CSO, Galvão MHR, Brito FM, et al. Leprosy: surveillance of contacts. Rev. enferm. UFPE [internet]. 2014 [acesso em 2018 jun 15]; 8(5):1136-41. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/9791.
https://periodicos.ufpe.br/revistas/revi...

23 Lobato DC, Neves DCO, Xavier MB. Avaliação das ações da vigilância de contatos domiciliares de pacientes com hanseníase no Município de Igarapé-Açu, Estado do Pará, Brasil. Rev. Pan-Amazônica Saúde [internet]. 2016 [acesso em 2018 jun 15]; 7(1):45-53. Disponível em:http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S2176-62232016000100006&lng=pt.
http://scielo.iec.gov.br/scielo.php?scri...
-2424 Romero-Montoya M, Beltran-Alzate JC, Cardona-Castro N. Evaluation and monitoring of mycobacterium leprae transmission in household contacts of patients with hansen's disease in Colombia. Plos negl. trop. dis. [internet]. 2017 [acesso em 2018 jun 15]; 11(1):e0005325. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5289623/.
https://www.ncbi.nlm.nih.gov/pmc/article...
. Study A2 emphasizes that the contacts of patients with MB leprosy in V Form presented a 3.8 times higher risk of developing leprosy than the contacts of patients with other clinical forms1818 Goulart IMB, Souza DOB, Marques CR, et al. Risk and Protective Factors for Leprosy Development Determined by Epidemiological Surveillance of Household Contacts. Clin Vaccine Immunol. [internet]. 2008 [acesso em 2018 jun 14]; 15(1):101-105. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223848/.
https://www.ncbi.nlm.nih.gov/pmc/article...
.

The degree of relatedness and inbreeding were also identified as risk factors for the disease, being higher in the first-degree relatives. Among the other risk factors associated with infection and illness are: no scar of Bacillus Calmette-Guérin (BCG), Mitsuda negative test or smaller than 5mm, positive ML-Flow test, young age (<20 years), and socioeconomic factors such as low schooling and income, as shown in chart 2.

Active surveillance of leprosy contacts

Six articles which evidenced contact surveillance were identified as the main epidemiological surveillance strategy for early diagnosis and contact tracing of patients with leprosy, highlighting the active search of household contacts as an important measure of disease control2525 Vieira CSCA, Soares MT, Ribeiro CTSX, et al. Avaliação e controle de contatos faltosos de doentes com hanseníase. Rev. bras. enferm. [internet]. 2008 [acesso em 2018 jun 15]; 61(spe):682-688. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S003471672008000700005&lng=en.
http://www.scielo.br/scielo.php?script=s...

26 Shen J, Wang Y, Zhou M, et al. Analysis on value of household contact survey in case detection of leprosy at a low endemic situation in China. Indian j. dermatol. venereol. leprol. [internet]. 2009 [acesso em 2018 jun 15]; 75:152-156. Disponível em: http://www.ijdvl.com/text.asp?2009/75/2/152/48660.
http://www.ijdvl.com/text.asp?2009/75/2/...

27 Peixoto BKS, Figueiredo IA, Caldas AJM, et al. Aspectos epidemiológicos dos contatos de hanseníase no Município de São Luís-MA. Hansen. int. [internet]. 2011 [acesso em 2018 jun 16]; 36(1):23-30. Disponível em: http://www.ilsl.br/revista/detalhe_artigo.php?id=11559#.
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28 Moura THM, Costa ACI, Rafael MEPP, et al. Controle dos contatos intradomiciliares de hanseníase em equipes de saúde da família. Rev. APS [internet]. 2012 [acesso em 2018 jun 16]; 15(2):139-147. Disponível em: https://aps.ufjf.emnuvens.com.br/aps/article/view/1468.
https://aps.ufjf.emnuvens.com.br/aps/art...

29 Hacker MA, Duppre NC, Nery JAC, et al. Characteristics of leprosy diagnosed through the surveillance of contacts: a comparison with index cases in Rio de Janeiro, 1987-2010. Mem. Inst. Oswaldo Cruz [internet]. 2012 [acesso em 2018 jun 15]; 107(supl1):49-54. Disponível em: http://www.scielo.br/pdf/mioc/v107s1/09.pdf.
http://www.scielo.br/pdf/mioc/v107s1/09....
-3030 Romanholo HSB, Souza EA, Ramos JAN, et al. Vigilância de contatos intradomiciliares de hanseníase: perspectiva do usuário em município hiperendêmico. Rev. bras. enferm. [internet]. 2018 [acesso em 2018 jun 15]; 71(1):163-169. Disponível em: http://www.scielo.br/pdf/reben/v71n1/0034-7167-reben-71-01-0163.pdf.
http://www.scielo.br/pdf/reben/v71n1/003...
, as highlighted in chart 3.

Study A9 compared contact surveillance and passive case detection, identifying that cases diagnosed by contact surveillance were found at the earliest stage, resulting in less severe clinical presentations, lower levels of disability, lower bacterial rates, and lower prevalence of disease reaction, indicating that active surveillance is especially important in areas of high endemicity, such as Brazil2929 Hacker MA, Duppre NC, Nery JAC, et al. Characteristics of leprosy diagnosed through the surveillance of contacts: a comparison with index cases in Rio de Janeiro, 1987-2010. Mem. Inst. Oswaldo Cruz [internet]. 2012 [acesso em 2018 jun 15]; 107(supl1):49-54. Disponível em: http://www.scielo.br/pdf/mioc/v107s1/09.pdf.
http://www.scielo.br/pdf/mioc/v107s1/09....
.

New strategies for control and surveillance of leprosy contacts

Of the six studies classified in this category, two were randomized clinical trials; four, observational; and one, descriptive. The studies have brought innovative strategies for contact surveillance used in other countries and developed in Brazil based on single dose rifampicin chemoprophylaxis3131 Moet FJ, Pahan D, Oskam L, et al. Effectiveness of single dose rifampicin in preventing leprosy in close contacts of patients with newly diagnosed leprosy: cluster randomised controlled trial. BMJ [internet]. 2008 [acesso em 2018 jun 2]; 336(7647):761-764. Disponível em: https://www.bmj.com/content/336/7647/761.long.
https://www.bmj.com/content/336/7647/761...
; Single Dose Rifampicin (SDR) chemoprophylaxis associated with immunoprophylaxis with BCG3232 Richardus RA, Alam K, Pahan D, et al. The combined effect of chemoprophylaxis with single dose rifampicin and immunoprophylaxis with BCG to prevent leprosy in contacts of newly diagnosed leprosy cases: a cluster randomized controlled trial (MALTALEP study). BMC infect. dis. [internet]. 2013 [acesso em 2018 jun 4]; 13(1):1-8. Disponível em: https://bmcinfectdis.biomedcentral.com/track/pdf/10.1186/1471-2334-13-456.
https://bmcinfectdis.biomedcentral.com/t...
; dosage of serum anti-PGL1 IgG/IgM and salivary anti-PGL1 IgA/IgM and detection of nasal carriage by M. leprae3333 Cabral PB, Júnior JEC, Macedo AC, et al. Anti-PGL1 salivary IgA/IgM, serum IgG/IgM, and nasal Mycobacterium leprae DNA in individuals with household contact with leprosy. Int. j. infect. dis. [internet]. 2013 [acesso em 2018 jun 22]; 17:e1005-e1010. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/23871279.
https://www.ncbi.nlm.nih.gov/pubmed/2387...
; mapping as a tool to identify areas at high risk for leprosy3434 Moura MLN, Dupnik KM, Sampaio GAA, et al. Active Surveillance of Hansen's Disease (Leprosy): Importance for Case Finding among Extra-domiciliary Contacts. Plos negl. trop. dis. [internet]. 2013 [acesso em 2018 jun 1]; 7(3):e2093. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3597486/pdf/pntd.0002093.pdf.
https://www.ncbi.nlm.nih.gov/pmc/article...
; use of the Self-Image Form (SIF) and surveillance of extra domiciliary contacts3535 Campos DCC, Dutra APB, Suares VL, et al. New strategies for active finding of leprosy cases in the Amazonian region. Rev. Soc. Bras. Med. Trop. [internet]. 2015 [acesso em 2018 jun 15]; 48(4):488-490. Disponível em: http://www.scielo.br/pdf/rsbmt/v48n4/1678-9849-rsbmt-48-04-00488.pdf.
http://www.scielo.br/pdf/rsbmt/v48n4/167...
; and the implementation of the Leprosy Post Exposure Prophylaxis (LPEP) program to evaluate the contact tracing, viability, efficacy and impact of Post-Exposure located in several endemic leprosy countries, Prophylaxis (PEP) with SDR in pilot areas including Brazil3636 Barth-Jaeggi T, Steinmann P, Mieras L, et al. Leprosy Post-Exposure Prophylaxis (LPEP) programme: study protocol for evaluating the feasibility and impact on case detection rates of contact tracing and single dose rifampicin. BMJ [internet] 2016 [acesso em 2018 jun 3]; 6:e013633. Disponível em: https://bmjopen.bmj.com/content/bmjopen/6/11/e013633.full.pdf.
https://bmjopen.bmj.com/content/bmjopen/...
, as shown in chart 4.

Discussions

Even after 30 years of the creation of the Unified Health System (SUS) and 27 years after the official implantation of the Polychemotherapy in Brazil, leprosy still constitutes a serious public health problem, since Brazil was unable to fulfill its commitment forged with WHO, neither in 1991, in 2005 nor in 2011, to eliminate it as a public health problem by 2015, that is, to reach the goal and reduce the prevalence to less than 1 case/10 thousand inhabitants in all Brazilian municipalities99 Organização Mundial de Saúde. Estratégia Global para Hanseníase 2016-2020: acelerar a ação para um mundo sem lepra. Geneva: OMS; 2016.,3737 Neto JMP, Carvalho HT, Cunha LES, et al. Análise do controle dos contatos intradomiciliares de pessoas atingidas pela hanseníase no Brasil e no estado de São Paulo de 1991 a 2012. Hansen Int. [internet] 2013 [acesso em 2018 jun 15]; 38(1-2):68-78. Disponível em: www.ilsl.br/revista/download.php?id=imageBank/v38n1-2a09.pdf.
www.ilsl.br/revista/download.php?id=imag...
.

It is known that social inequities determine the persistence and difficulties of controlling Neglected Tropical Diseases (NTDs), causing greater vulnerability and risk of these diseases. With regard to leprosy, poverty is a determining factor for its occurrence and transmission. Variables as bad housing conditions; lack of access to public services, such as sanitation, garbage collection and piped water; and lack of hygiene were significantly associated with leprosy3838 Monteiro LD, Mota RMS, Martins-Melo FR, et al. Determinantes sociais da hanseníase em um estado hiperendêmico da região norte do Brasil. Rev. Saude Publica [internet]. 2017 [acesso em 2018 jun 2]; 51:70. Disponível em: http://www.rsp.fsp.usp.br/artigo/determinantes-sociais-da-hanseniase-em-um-estado-hiperendemico-da-regiao-norte-do-brasil/.
http://www.rsp.fsp.usp.br/artigo/determi...
.

The high endemicity of leprosy allows multiple exposures of the population to the bacillus, even in the first years of life3939 Lana FCF, Fabri ACOC, Lopes FNL, et al. Deformities due to leprosy in children under fifteen years old as an indicator of quality of the leprosy control programme in brazilian municipalities. J. Trop. Med. [internet]. 2013 [acesso em 2018 jun 3]; (36)812793:1-6. Disponível em: https://www.hindawi.com/journals/jtm/2013/812793/.
https://www.hindawi.com/journals/jtm/201...
. The detection of new cases in young contacts, and, especially, in children under 15 years of age is directly related to the focus of active transmission2323 Lobato DC, Neves DCO, Xavier MB. Avaliação das ações da vigilância de contatos domiciliares de pacientes com hanseníase no Município de Igarapé-Açu, Estado do Pará, Brasil. Rev. Pan-Amazônica Saúde [internet]. 2016 [acesso em 2018 jun 15]; 7(1):45-53. Disponível em:http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S2176-62232016000100006&lng=pt.
http://scielo.iec.gov.br/scielo.php?scri...
. Low schooling directly interferes with the difficulty of understanding the information disclosed about leprosy, reflecting even a large number of unemployed and self-employed workers, implying low monthly income, which are factors associated with the lack and abandonment of polychemotherapy4040 Brito KKG, Andrade SSC, Diniz IV, et al. Caracterização dos casos de hanseníase diagnosticados através do exame de contato. Rev. enferm. UFPE on line [internet]. 2016 [acesso em 2018 jul 4]; 10(2):435-41. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/download/10974/12309.
https://periodicos.ufpe.br/revistas/revi...
,4141 Souza AA, Oliveira FJF, Costa ACJ, et al. Adesão ao tratamento da hanseníase por pacientes acompanhados em unidades básicas de saúde de Imperatriz-MA. Sanare (Sobral) [internet]. 2013 [acesso em 2015 jul 6]; 12(1):6-12. Disponível em: http://www.repositorio.ufc.br/handle/riufc/7588.
http://www.repositorio.ufc.br/handle/riu...
.

Household contacts of leprosy patients presented a higher risk for infection and illness, and factors, such as genetic susceptibility and the clinical form of the index case, are directly related to a higher incidence of the disease, results already widely documented in the literature22 Brasil. Ministério da Saúde, Secretaria de Políticas de Saúde, Departamento de Atenção Básica. Guia para o Controle da hanseníase. Brasília, DF: Ministério da Saúde; 2002.,44 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Boletim Epidemiológico - Hanseníase. Brasília, DF: Ministério da Saúde; 2018.,77 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Guia de vigilância em saúde. Brasília, DF: Ministério da Saúde. 2014.,4242 Lana CFC, Carvalho APM, Davi RFL. Perfil epidemiológico da hanseníase na microrregião de Araçuaí e sua relação com ações de controle. Esc. Anna Nery [internet]. 2011 [acesso em 2018 jul 3]; 15(1):62-67. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452011000100009.
http://www.scielo.br/scielo.php?script=s...
.

The occurrence of new cases among consanguineous household contacts of the index case, mainly, first-degree relatives, presented a probability 2.05 times higher in relation to other types of parentage, evidencing the importance of genetic susceptibility in the chain of transmission of the disease1919 Dessunti EM, Soubhia Z, Alves E, et al. Hanseníase: o controle dos contatos no município de Londrina-PR em um período de dez anos. Rev. bras. enferm. [internet]. 2008 [acesso em 2018 jun 15]; 61(spe):689-693. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S003471672008000700006&lng=en.
http://www.scielo.br/scielo.php?script=s...
,2020 Durães SMB, Guedes LS, Cunha MD, et al. Estudo epidemiológico de 107 focos familiares de hanseníase no município de Duque de Caxias - Rio de Janeiro, Brasil. An. bras. dermatol. [internet]. 2010 [acesso em 2018 jun 15]; 85(3):339-345. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S036505962010000300007&lng=en.
http://www.scielo.br/scielo.php?script=s...
,2222 Lima CSO, Galvão MHR, Brito FM, et al. Leprosy: surveillance of contacts. Rev. enferm. UFPE [internet]. 2014 [acesso em 2018 jun 15]; 8(5):1136-41. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/9791.
https://periodicos.ufpe.br/revistas/revi...
,2424 Romero-Montoya M, Beltran-Alzate JC, Cardona-Castro N. Evaluation and monitoring of mycobacterium leprae transmission in household contacts of patients with hansen's disease in Colombia. Plos negl. trop. dis. [internet]. 2017 [acesso em 2018 jun 15]; 11(1):e0005325. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5289623/.
https://www.ncbi.nlm.nih.gov/pmc/article...
. As to the clinical form of the disease, it was found that the contacts of patients with MB leprosy in its V form presented a 3.8 times higher risk of leprosy development than the contacts of patients with the other clinical forms1818 Goulart IMB, Souza DOB, Marques CR, et al. Risk and Protective Factors for Leprosy Development Determined by Epidemiological Surveillance of Household Contacts. Clin Vaccine Immunol. [internet]. 2008 [acesso em 2018 jun 14]; 15(1):101-105. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223848/.
https://www.ncbi.nlm.nih.gov/pmc/article...
,2323 Lobato DC, Neves DCO, Xavier MB. Avaliação das ações da vigilância de contatos domiciliares de pacientes com hanseníase no Município de Igarapé-Açu, Estado do Pará, Brasil. Rev. Pan-Amazônica Saúde [internet]. 2016 [acesso em 2018 jun 15]; 7(1):45-53. Disponível em:http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S2176-62232016000100006&lng=pt.
http://scielo.iec.gov.br/scielo.php?scri...
. The data reinforce the need for an early diagnosis and an appropriate treatment institution, which contributes to a decrease in the period of exposure of contacts to cases, mainly to MB1919 Dessunti EM, Soubhia Z, Alves E, et al. Hanseníase: o controle dos contatos no município de Londrina-PR em um período de dez anos. Rev. bras. enferm. [internet]. 2008 [acesso em 2018 jun 15]; 61(spe):689-693. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S003471672008000700006&lng=en.
http://www.scielo.br/scielo.php?script=s...
.

Home contacts with no BCG scar were 3.7 times more likely to develop leprosy when compared to contacts with one or more scars. Regarding the Mitsuda test, the household contacts that obtained a ≤ 7 mm Mitsuda score had an estimated 6.25 times higher risk of disease when compared to positive contacts (8 to ≥ 10 mm)1818 Goulart IMB, Souza DOB, Marques CR, et al. Risk and Protective Factors for Leprosy Development Determined by Epidemiological Surveillance of Household Contacts. Clin Vaccine Immunol. [internet]. 2008 [acesso em 2018 jun 14]; 15(1):101-105. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223848/.
https://www.ncbi.nlm.nih.gov/pmc/article...
. The ML-Flow test identified that positive results with 10.4% titration between affected contacts compared to healthy contacts represent a nearly six-fold increased relative risk for disease onset2121 Sarno EN, Duarte NC, Vendas AM, et al. Exposição à hanseníase, infecção e doença: um estudo de vigi lância de 25 anos dos contatos de pacientes com hanseníase. Mem. Inst. Oswaldo Cruz [internet]. 2012 [acesso em 2018 jun 15]; 107(8):1054-1059. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0074-02762012000800015&lng=en.
http://www.scielo.br/scielo.php?script=s...
. It was observed that all unfavorable combinations of two and three tests generated significant risk values ranging from 5.76 to 24.47, with the highest risk represented by the combination of no BCG scars, a negative Mitsuda test and one ML-Flow1818 Goulart IMB, Souza DOB, Marques CR, et al. Risk and Protective Factors for Leprosy Development Determined by Epidemiological Surveillance of Household Contacts. Clin Vaccine Immunol. [internet]. 2008 [acesso em 2018 jun 14]; 15(1):101-105. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223848/.
https://www.ncbi.nlm.nih.gov/pmc/article...
,2121 Sarno EN, Duarte NC, Vendas AM, et al. Exposição à hanseníase, infecção e doença: um estudo de vigi lância de 25 anos dos contatos de pacientes com hanseníase. Mem. Inst. Oswaldo Cruz [internet]. 2012 [acesso em 2018 jun 15]; 107(8):1054-1059. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0074-02762012000800015&lng=en.
http://www.scielo.br/scielo.php?script=s...
positive test.

It is emphasized that BCG vaccination is important in clinical and epidemiological practice and that maintaining the additional dose of BCG in contacts is an important strategy for leprosy control programs, aiming to protect contacts, especially against MB2323 Lobato DC, Neves DCO, Xavier MB. Avaliação das ações da vigilância de contatos domiciliares de pacientes com hanseníase no Município de Igarapé-Açu, Estado do Pará, Brasil. Rev. Pan-Amazônica Saúde [internet]. 2016 [acesso em 2018 jun 15]; 7(1):45-53. Disponível em:http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S2176-62232016000100006&lng=pt.
http://scielo.iec.gov.br/scielo.php?scri...
,3030 Romanholo HSB, Souza EA, Ramos JAN, et al. Vigilância de contatos intradomiciliares de hanseníase: perspectiva do usuário em município hiperendêmico. Rev. bras. enferm. [internet]. 2018 [acesso em 2018 jun 15]; 71(1):163-169. Disponível em: http://www.scielo.br/pdf/reben/v71n1/0034-7167-reben-71-01-0163.pdf.
http://www.scielo.br/pdf/reben/v71n1/003...
forms. The Mitsuda test was not standardized by the WHO for clinical classification or epidemiological studies, since the WHO leprosy classification system was based on the number of lesions in PB and MB4343 World Health Organization. Guide to eliminate leprosy as a public health problem. Geneva: WHO; 2000.. However, studies have shown that the application of the Mitsuda test in endemic regions may be an important epidemiological approach to monitor household contacts1818 Goulart IMB, Souza DOB, Marques CR, et al. Risk and Protective Factors for Leprosy Development Determined by Epidemiological Surveillance of Household Contacts. Clin Vaccine Immunol. [internet]. 2008 [acesso em 2018 jun 14]; 15(1):101-105. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223848/.
https://www.ncbi.nlm.nih.gov/pmc/article...
,2121 Sarno EN, Duarte NC, Vendas AM, et al. Exposição à hanseníase, infecção e doença: um estudo de vigi lância de 25 anos dos contatos de pacientes com hanseníase. Mem. Inst. Oswaldo Cruz [internet]. 2012 [acesso em 2018 jun 15]; 107(8):1054-1059. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0074-02762012000800015&lng=en.
http://www.scielo.br/scielo.php?script=s...
. The ML-Flow test, which is an alternative method to Elisa for the detection of IgM anti-PGL-1 antibodies, does not constitute a diagnostic test but rather an examination for the classification of patients in PB and MB and to aid in the therapeutic decision4444 Contin LA, Alves CJM, Fogagnolo L, et al. Uso do teste ML-Flow como auxiliar na classificação e tratamento da hanseníase. An. Bras. Dermatol. [internet]. 2011 [acesso em 2018 jul 1]; 86(1):91-95. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962011000100012.
http://www.scielo.br/scielo.php?script=s...
.

Studies show that the main strategy to reduce the burden of leprosy and the extent of disease control as a public health problem at the national level is necessarily due to the surveillance and qualified approach of leprosy case contacts44 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Boletim Epidemiológico - Hanseníase. Brasília, DF: Ministério da Saúde; 2018.,2020 Durães SMB, Guedes LS, Cunha MD, et al. Estudo epidemiológico de 107 focos familiares de hanseníase no município de Duque de Caxias - Rio de Janeiro, Brasil. An. bras. dermatol. [internet]. 2010 [acesso em 2018 jun 15]; 85(3):339-345. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S036505962010000300007&lng=en.
http://www.scielo.br/scielo.php?script=s...
,2222 Lima CSO, Galvão MHR, Brito FM, et al. Leprosy: surveillance of contacts. Rev. enferm. UFPE [internet]. 2014 [acesso em 2018 jun 15]; 8(5):1136-41. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/9791.
https://periodicos.ufpe.br/revistas/revi...
,4545 Ramos Jr AN, Oliveira MLW, Barbosa JC, et al. Pesquisas em hanseníase: Contextos e agendas. In. Universidade de Brasília-UnB. Hanseníase: avanços e desafios. Brasília, DF: Nesprom. 2014. p. 455-90.

46 Bratschi MW, Steinmann P, Wickenden A, et al. Current knowledge on mycobacterium leprae transmission: a systematic literature review. Lepr. Rev. [internet]. 2015 [acesso em 2018 jun 3]; 86:142-55. Disponível em: https://www.researchgate.net/profile/Peter_Steinmann/publication/281030220_Current_knowledge_on_Mycobacterium_leprae_transmission_A_systematic_literature_review/links/55d1ace908ae502646aa5dc0.pdf.
https://www.researchgate.net/profile/Pet...
-4747 Smith WC, Aerts A. Role of contact tracing and prevention strategies in the interruption of leprosy transmission. Lepr. Rev. [internet]. 2014 [acesso em 2016 jun 13]; 85(1):2-17. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/24974438.
https://www.ncbi.nlm.nih.gov/pubmed/2497...
. However, contact surveillance has been undervalued and even neglected in the public health services that develop the actions of the National Leprosy Eradication Programme (NLEP); since it privileges the space for disease and patient control, re-electing the control actions of the contacts to a secondary plan3737 Neto JMP, Carvalho HT, Cunha LES, et al. Análise do controle dos contatos intradomiciliares de pessoas atingidas pela hanseníase no Brasil e no estado de São Paulo de 1991 a 2012. Hansen Int. [internet] 2013 [acesso em 2018 jun 15]; 38(1-2):68-78. Disponível em: www.ilsl.br/revista/download.php?id=imageBank/v38n1-2a09.pdf.
www.ilsl.br/revista/download.php?id=imag...
.

Contact surveillance is the main strategy for the active detection of cases of leprosy44 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Boletim Epidemiológico - Hanseníase. Brasília, DF: Ministério da Saúde; 2018.,1313 Hacker MA, Duppre NC, Nery JAC, et al. Characteristics of leprosy diagnosed through the surveillance of contacts: a comparison with index cases in Rio de Janeiro, 1987-2010. Mem. Inst. Oswaldo Cruz [internet]. 2012 [acesso em 2018 Jun 2]; 107:49-54. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0074-02762012000900009.
http://www.scielo.br/scielo.php?script=s...
, with the purpose of discovering new cases among those who live or have lived together, in a prolonged way, with the index case and also aims to discover their possible sources of infection in the domicile or outside it (social), regardless of the patient’s operational classification - PB or MB1.

In China, in regions with low leprosy endemicity, it was identified that the active search through the contact survey and the dermatoneurological examination ranked first among the methods of leprosy detection among the contacts2626 Shen J, Wang Y, Zhou M, et al. Analysis on value of household contact survey in case detection of leprosy at a low endemic situation in China. Indian j. dermatol. venereol. leprol. [internet]. 2009 [acesso em 2018 jun 15]; 75:152-156. Disponível em: http://www.ijdvl.com/text.asp?2009/75/2/152/48660.
http://www.ijdvl.com/text.asp?2009/75/2/...
. A comparison made between the epidemiological characteristics of the cases diagnosed by contact surveillance and the passively detected cases in Brazil showed that the contacts diagnosed through contact surveillance presented less severe clinical forms, lower levels of disability, lower bacillary load and reaction prevalence1313 Hacker MA, Duppre NC, Nery JAC, et al. Characteristics of leprosy diagnosed through the surveillance of contacts: a comparison with index cases in Rio de Janeiro, 1987-2010. Mem. Inst. Oswaldo Cruz [internet]. 2012 [acesso em 2018 Jun 2]; 107:49-54. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0074-02762012000900009.
http://www.scielo.br/scielo.php?script=s...
.

However, when assessing the proportion of contacts examined among those registered over the years 2002 to 2011 in Brazil, it was verified that this proportion did not exceed 60%; and that, between the years 2012 and 2014, there was a slight increase to 74%, still not reaching satisfactory rates4848 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Indicadores epidemiológicos e operacionais de hanseníase, Brasil 2000-2014 [internet]. Portal da Saúde. 2016 [acesso em 2018 jun 28]. Disponível em: http://portalsaude.saude.gov.br/images/pdf/2015/outubro/29/S--rie-Hist--rica-Hansen--ase-2000---2014.pdf.
http://portalsaude.saude.gov.br/images/p...
.

It should be emphasized that, for active surveillance, measures to evaluate and control contacts and integration of these actions at different levels of attention should be intensified, seeking to promote the access of the population to health services, facilitating early diagnosis, contributing to the interruption of the transmission and, consequently, reducing the deficiencies and incapacities, which, ultimately, represent a strong social, economic and psychological impact for the patients44 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Boletim Epidemiológico - Hanseníase. Brasília, DF: Ministério da Saúde; 2018.,2828 Moura THM, Costa ACI, Rafael MEPP, et al. Controle dos contatos intradomiciliares de hanseníase em equipes de saúde da família. Rev. APS [internet]. 2012 [acesso em 2018 jun 16]; 15(2):139-147. Disponível em: https://aps.ufjf.emnuvens.com.br/aps/article/view/1468.
https://aps.ufjf.emnuvens.com.br/aps/art...

29 Hacker MA, Duppre NC, Nery JAC, et al. Characteristics of leprosy diagnosed through the surveillance of contacts: a comparison with index cases in Rio de Janeiro, 1987-2010. Mem. Inst. Oswaldo Cruz [internet]. 2012 [acesso em 2018 jun 15]; 107(supl1):49-54. Disponível em: http://www.scielo.br/pdf/mioc/v107s1/09.pdf.
http://www.scielo.br/pdf/mioc/v107s1/09....
-3030 Romanholo HSB, Souza EA, Ramos JAN, et al. Vigilância de contatos intradomiciliares de hanseníase: perspectiva do usuário em município hiperendêmico. Rev. bras. enferm. [internet]. 2018 [acesso em 2018 jun 15]; 71(1):163-169. Disponível em: http://www.scielo.br/pdf/reben/v71n1/0034-7167-reben-71-01-0163.pdf.
http://www.scielo.br/pdf/reben/v71n1/003...
.

Regarding strategies, this review made it possible to identify new strategies for control and surveillance of leprosy contacts through the implementation of innovative tools and methodologies that favor the interruption of transmission of M. leprae and early detection of new cases among contacts.

A randomized clinical trial carried out in Bangladesh with 21,711 contacts has found a 57% reduction in the overall incidence of leprosy among the contacts of patients newly diagnosed with the administration of SDR after two years of treatment, with, therefore, SDR being 57% effective in prevention of the development of clinical leprosy. The use of SDR is a promising, preventive, cheap and practical intervention for contacts of patients with leprosy in leprosy control programs3131 Moet FJ, Pahan D, Oskam L, et al. Effectiveness of single dose rifampicin in preventing leprosy in close contacts of patients with newly diagnosed leprosy: cluster randomised controlled trial. BMJ [internet]. 2008 [acesso em 2018 jun 2]; 336(7647):761-764. Disponível em: https://www.bmj.com/content/336/7647/761.long.
https://www.bmj.com/content/336/7647/761...
.

Another study developed in Bangladesh with approximately 20 thousand contacts examined the combined effect of chemoprophylaxis with SDR and immunoprophylaxis with BCG to prevent leprosy in contacts of newly diagnosed cases. The combination of these measures is potentially a very effective and innovative tool for the contacts of leprosy patients, which can significantly reduce the transmission of M. leprae3232 Richardus RA, Alam K, Pahan D, et al. The combined effect of chemoprophylaxis with single dose rifampicin and immunoprophylaxis with BCG to prevent leprosy in contacts of newly diagnosed leprosy cases: a cluster randomized controlled trial (MALTALEP study). BMC infect. dis. [internet]. 2013 [acesso em 2018 jun 4]; 13(1):1-8. Disponível em: https://bmcinfectdis.biomedcentral.com/track/pdf/10.1186/1471-2334-13-456.
https://bmcinfectdis.biomedcentral.com/t...
.

In view of the evidence, as unprecedent intervention, LPEP is being implemented in pilot areas located in several countries endemic for leprosy: India, Indonesia, Myanmar, Nepal, Sri Lanka, Tanzania, Cambodia and Brazil in order to evaluate the viability, efficacy and the impact of the PEP with SDR with a view to speeding the acceptance of this intervention and the introduction of the PEP in national leprosy programs3636 Barth-Jaeggi T, Steinmann P, Mieras L, et al. Leprosy Post-Exposure Prophylaxis (LPEP) programme: study protocol for evaluating the feasibility and impact on case detection rates of contact tracing and single dose rifampicin. BMJ [internet] 2016 [acesso em 2018 jun 3]; 6:e013633. Disponível em: https://bmjopen.bmj.com/content/bmjopen/6/11/e013633.full.pdf.
https://bmjopen.bmj.com/content/bmjopen/...
.

The ‘PEP-Hans’ project coming from this initiative is under development in Brazil and explores the administration of chemoprophylaxis and immunoprophylaxis (SDR and BCG) to about 20 contacts per index patient. The project is being implemented in 16 municipalities in the states of Mato Grosso, Pernambuco and Tocantins and covers patients diagnosed from 2015 to 2017. It is estimated that 850 patients with 17,000 contacts will be included each year. The LPEP program will help translate existing evidence on SDR PEP to reduce the risk of developing leprosy between contacts of leprosy patients in routine actions, providing solid data from a range of settings and conditions established by the national programs themselves for the control of leprosy3636 Barth-Jaeggi T, Steinmann P, Mieras L, et al. Leprosy Post-Exposure Prophylaxis (LPEP) programme: study protocol for evaluating the feasibility and impact on case detection rates of contact tracing and single dose rifampicin. BMJ [internet] 2016 [acesso em 2018 jun 3]; 6:e013633. Disponível em: https://bmjopen.bmj.com/content/bmjopen/6/11/e013633.full.pdf.
https://bmjopen.bmj.com/content/bmjopen/...
.

Still in Brazil, 30 patients with leprosy and 135 household contacts were evaluated for and salivary anti-PGL1 IgA/IgM and detection of nasal carriage by M. leprae. Salivary anti-PGL1 IgA/IgM and serum anti-PGL1 IgG antibodies showed a good correlation comparing contacts and index cases (p<0.01, p<0.005 and p<0.0001, respectively). High frequency of positive IgM anti-PGL1 was found in negative samples for IgG. The results of the study pointed out that both isotypes should always be measured. Serum anti-PGL1 IgG/IgM and salivary anti-PGL1 IgA/IgM measurements are strongly suggested for follow-up of household contacts of leprosy3333 Cabral PB, Júnior JEC, Macedo AC, et al. Anti-PGL1 salivary IgA/IgM, serum IgG/IgM, and nasal Mycobacterium leprae DNA in individuals with household contact with leprosy. Int. j. infect. dis. [internet]. 2013 [acesso em 2018 jun 22]; 17:e1005-e1010. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/23871279.
https://www.ncbi.nlm.nih.gov/pubmed/2387...
.

The grouping/mapping was evaluated as a tool to identify high risk areas of leprosy and the usefulness of the dermatoneurological examination during home visits. The spatial analysis identified a group of newly diagnosed cases and an association with the residential coordinates of previously diagnosed MB cases, showing that in hyperendemic areas the risk of the disease is high in social contacts. The distribution of PB cases was not random and depended on the presence of MB cases. The mapping associated with the dermatoneurological examination of extra domiciliary contacts has been shown to be effective for detecting new cases among leprosy contacts, especially those living close to a MB3434 Moura MLN, Dupnik KM, Sampaio GAA, et al. Active Surveillance of Hansen's Disease (Leprosy): Importance for Case Finding among Extra-domiciliary Contacts. Plos negl. trop. dis. [internet]. 2013 [acesso em 2018 jun 1]; 7(3):e2093. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3597486/pdf/pntd.0002093.pdf.
https://www.ncbi.nlm.nih.gov/pmc/article...
case.

In the Amazon region, it was verified that the search of cases among neighbors with leprosy using SIF increases the notification of new cases of leprosy in 17.5%. The active search for leprosy cases among contacts, including widening the scope of research to neighbors in at least a 200 meters radius of residence of the index case, combined with the use of a modified SIF (inclusion of a question about the presence of anesthetic areas) is a simple, low-cost, efficient and feasible implementation within the context of Primary Health Care (PHC)3535 Campos DCC, Dutra APB, Suares VL, et al. New strategies for active finding of leprosy cases in the Amazonian region. Rev. Soc. Bras. Med. Trop. [internet]. 2015 [acesso em 2018 jun 15]; 48(4):488-490. Disponível em: http://www.scielo.br/pdf/rsbmt/v48n4/1678-9849-rsbmt-48-04-00488.pdf.
http://www.scielo.br/pdf/rsbmt/v48n4/167...
.

Final considerations

This review has updated knowledge about control and epidemiological surveillance of leprosy contacts. The analysis of the literature indicates that there is a concentration of studies aimed at prevention and control of the disease among the contacts, mainly, focusing on the identification of risk factors and implementation of surveillance actions through the active search of new cases. However, the evidences indicate new strategies and effective tools that can be incorporated into clinical practice in health services or associated with existing ones, aiming at the early detection and interruption of transmission of M. leprae for the elimination of leprosy as a public health problem in the Country.

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    Orcid (Open Researcher and Contributor ID).

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History

  • Received
    23 July 2018
  • Accepted
    02 Feb 2019
Centro Brasileiro de Estudos de Saúde RJ - Brazil
E-mail: revista@saudeemdebate.org.br