Protocol, rationale and design of PEOPLE (Post ExpOsure Prophylaxis for LEprosy in the Comoros and Madagascar): a cluster randomized trial on effectiveness of different modalities of implementation of post-exposure prophylaxis of leprosy contacts

Abstract

BackgroundLeprosy is an ancient infectious disease with a global annual incidence that has plateaued above 200,000 new cases since over a decade. New strategies are required to overcome this stalemate. Post-exposure prophylaxis (PEP) with a single dose of Rifampicin (SDR) has conditionally been recommended by the World Health Organization (WHO), based on a randomized-controlled-trial in Bangladesh. More evidence is required. The Post ExpOsure Prophylaxis for Leprosy (PEOPLE) trial will assess effectiveness of different modalities of PEP on the Comoros and Madagascar.MethodsPEOPLE is a cluster-randomized trial with villages selected on previous leprosy-incidence and randomly allocated to four arms. Four annual door-to-door surveys will be performed in all arms. All consenting permanent residents will be screened for leprosy. Leprosy patients will be treated according to international guidelines and eligible contacts will be provided with SDR-PEP.Arm-1 is the comparator in which no PEP will be provided. In arms 2, 3 and 4, SDR-PEP will be provided at double the regular dose (20 mg/kg) to eligible contacts aged two years and above. In arm 2 all household-members of incident leprosy patients are eligible. In arm 3 not only household-members but also neighbourhood contacts living within 100-m of an incident case are eligible. In arm 4 such neighbourhood contacts are only eligible if they test positive to anti-PGL-I, a serological marker. Incidence rate ratios calculated between the comparator arm 1 and each of the intervention arms will constitute the primary outcome.DiscussionDifferent trials on PEP have yielded varying results. The pivotal COLEP trial in Bangladesh showed a 57% reduction in incidence over a two-year period post-intervention without any rebound in the following years. A study in a high-incidence setting in Indonesia showed no effect of PEP provided to close contacts but a major effect of PEP provided as a blanket measure to an entire island population. High background incidence could be the reason of the lack of effect of PEP provided to individual contacts. The PEOPLE trial will assess effectiveness of PEP in a high incidence setting and will compare three different approaches, to identify who benefits most from PEP.Trial registrationClinicaltrials.Gov. NCT03662022. Initial Protocol Version 1.2, 27-Aug-2018.

Prototype multi-biomarker test for point-of-care leprosy diagnostics

“…The NUM score provides a quick interpretation of the test result suitable for large-scale screening studies, for instance, to identify M. leprae -infected individuals that contribute to the perpetuating transmission. HCs of patients with MB leprosy are at the highest risk of acquiring M. leprae infection ( Bakker et al., 2006 ; Goulart et al., 2008 ; Sales et al., 2011 ) and thus represent candidates for preventive drug administration in multiple studies ( Barth-Jaeggi et al., 2016 ; Mieras et al., 2018 ; Ortuno-Gutierrez et al., 2019b ; Richardus et al., 2020 ; Tiwari et al., 2020 ) to prevent progress to leprosy disease, as well as decrease transmission. Since June 2018, the WHO guidelines for leprosy control have included single-dose rifampicin as PEP for leprosy prevention ( World Health Organization, 2018 ).…”

Efficacy of chemoprophylaxis and immunoprophylaxis in leprosy prevention: a systematic review and network meta-analysis of randomized controlled trials

“…Besides, Moraes et al, (46) was a comment paper, not full article, from our exclusion criteria, and there was no enough biostatics data to analysis it so we could not include it in our study. We found also Ortuno et al, (47) which was still protocol with no published full article for it yet, so we excluded it as from our exclusion criteria. Schouring et al (17) has shown that BCG vaccination at infancy reduces the risk of leprosy by 50% and combined BCG vaccination -at infancy-and SDR decreases risk by 80%.…”

Leprosy postexposure prophylaxis with single-dose rifampicin: Nepalese dermatologist’s dilemma

“…Newer trials like Post Exposure Prophylaxis for Leprosy (PEOPLE) in the Comoros and Madagascar uses double dose of rifampicin (20 mg/kg) to the contacts [ 14 ], and PEP ++ combines rifampicin with either clarithromycin or moxifloxacin (a fluoroquinolone with potential side effects) for 3 once monthly doses [ 15 ]. Both of these studies use different doses and/or combinations of rifampicin.…”