Background Leprosy transmission is ongoing; globally and within Bangladesh. Household contacts of leprosy cases are at increased risk of leprosy development. Identification of household contacts at highest risk would optimize this process. Methods The temporal pattern of new case presentation amongst household contacts was documented in the COCOA (Contact Cohort Analysis) study. The COCOA study actively examined household contacts of confirmed leprosy index cases identified in 1995, and 2000–2014, to provide evidence for timings of contact examination policies. Data was available on 9527 index cases and 38303 household contacts. 666 household contacts were diagnosed with leprosy throughout the follow-up (maximum follow-up of 21 years). Risk factors for leprosy development within the data analysed, were identified using Cox proportional hazard regression. Findings The dominant risk factor for household contacts developing leprosy was having a highly skin smear positive index case in the household. As the grading of initial slit skin smear of the index case increased from negative to high positive (4–6), the hazard of their associated household contacts developing leprosy increases by 3.14 times (p<0.001). Being a blood relative was not a risk factor, no gender differences in susceptibility were found. Interpretation We found a dominance of a single variable predicting risk for leprosy transmission–skin smear positive index cases. A small number of cases are maintaining transmission in the household setting. Focus should be performing contact examinations on these households and detecting new skin smear positive index cases. Conducting slit-skin smears on new cases is needed for predicting risk; such services need supporting. If skin smear positive cases are sustaining leprosy infection within the household setting, the administration of single-dose rifampicin (SDR) to household contacts as the sole intervention in Bangladesh will not be effective.

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The digital health revolution is a current hot topic within global health. The rhetoric, driven from the WHO's Global Strategy on Digital Health 2020-2025, is that the future of healthcare is digital. The vision for countries to implement eHealth was initiated as long ago as 2005 by the World Health Assembly urging member states to focus on long-term plans for the incorporation of digital technologies. 1 The WHO is committed to supporting countries to prioritize, integrate and regulate digital technologies. Through promoting equitable and affordable care, the incorporation of digital health has the potential to address the disparity in access to healthcare in Low-or Middle-Income Countries, aiding the achievement of universal health coverage. 1 Artificial Intelligence (AI) (a subset of machine learning) and deep learning, is based on pattern recognition enabling digital machines to undertake problem solving activities normally requiring human intelligence. Through experience and repeated exposure, AI machines adapt without the intervention of a human programmer. 2 The advent of successfully incorporated digital technologies into health systems supports the revolution of a digital-led future. An AI computer reading mammograms called Mia (Mammography Intelligent Assessment) has been introduced to address the current breast screening problem in the UK. 3 The NHS is experiencing a 50% shortfall in the number of practising breast radiologists (24% of whom will retire within the next five years). Radiologists are able to read up to 200 mammograms per day; Mia can read 200,000 a day, with continually improving accuracy. 4 Designed to be the second reader in the workflow, Mia is focused on improving workflow efficiency and reducing resource burdens. The potential benefit of introducing Mia to breast cancer screening is significant and should instil confidence within our community of the successful incorporation of digital technology into leprosy care.The application of digital technology is an area that has been little used or studied in leprosy thus far -this needs to change. The use of innovative digital technologies incorporated into mapping, diagnostic tools, health information systems and patient management has

Objectives We determined the male and female ratio of new leprosy cases detected over 15 years, allowing future exploration of inequalities pertaining to biological sex and social aspects of gender, which negatively impact women. Methods We extracted sex-disaggregated data from the annual Weekly Epidemiological Record (WER) Global leprosy situation reports, from 2004 to 2020, to determine the temporal pattern of new cases detected, by gender. Results Sex disaggregated leprosy data was only consistently reported in WER papers from 2004. The absolute number of female cases detected has remained static over the last 15 years (80,000-90,000 new cases annually). A 56.2% reduction in the number of male cases was observed from 2004-2019, whereas amongst females the reduction was only 37.5%. The difference in gender-specific reduction in case detection was similar in 5 of 6 WHO regions. There is a clear trend of increasing female percent amongst new cases detected from 2004 onwards; 30.8% of all new cases detected in 2004 were female, rising to 38.9% in 2019. Conclusions Sex-disaggregated data reporting at the national and international level needs to remain a priority. Further research is needed to understand why the percentage of new female cases detected amongst all new cases is increasing and the role biological factors play in leprosy transmission.