The impact of COVID-19 on persons affected by leprosy and leprosy control in the North and Northeast of Brazil. (2024)

Introduction

Over the past years, Brazil has been affected by multiple crises in the economic, political, social and health field. This resulted in difficulties in expanding the coverage and quality of health promotion campaigns, especially in areas with greater social and operational vulnerability, such as in the North and Northeast regions. (1,2) In this context, diseases recognized as neglected, such as leprosy, are more likely to cause damage at individual, family and community health level because of limited surveillance, case detection and treatment availability. Brazil, a nation profoundly affected by the Covid-19 virus, faced significant challenges stemming from the pandemic, including high rates of mortality and morbidity and a deepening economic crisis. (1) The impact of the pandemic is also reflected in the significant decrease in leprosy detection rate: from 27,864 new cases in 2019, to 17,979 new cases in 2020. (3)

In 2021, 140,594 new cases of leprosy were reported to the World Health Organization (WHO) and 19,826(14.1%) of them occurred in the Americas region, of which 18,318 (92.4%) in Brazil. (4) Brazil is the second country when looking at newly detected leprosy patients globally. Leprosy remains a cause of illness, physical disability, psychosocial distress, and stigma. The disease demands increased attention from health services to break the cycles of poverty and illness that impact multiple generations. (5,6)

Some major challenges in leprosy control stem from fragmented control approaches within healthcare networks, particularly given the chronic and complex progression of this disease. In addition to comprehensive care, leprosy services demand greater integration of healthcare and surveillance across Brazilian territories, alongside effective promotion of dignified living conditions for affected individuals and their families. The impact of Covid-19 on leprosy control has led to a reduction in the coverage of surveillance activities for contacts of leprosy patients in the country. (3,7,8)

As future crises, such as pandemics, are likely to occur, higher educational institutions, the social sector, health services as well as governmental and non-governmental organizations need to outline strategies that can contribute to minimize negative effects for marganalized groups. (9,10,11) Therefore, it is important to develop a deeper understanding of the psychosocial and health impacts of the pandemic on individuals affected by leprosy, particularly in regions of heightened vulnerability. This knowledge will be valuable for effectively addressing their needs both presently and in the future. The objective of the present study is to define the psychosocial and health status and needs of individuals affected by leprosy during the Covid-19 pandemic in municipalities in the North and Northeast of Brazil.

Methods

STUDY DESIGN AND POPULATION

This is a cross-sectional study with descriptive and analytical components, including persons affected by leprosy over 18 years of age, registered in the years 2019 and 2020 in the National System of Notifiable Diseases (SINAN). The study enrolled people undergoing multidrug therapy (MDT), including patients classified as relapse.

STUDY SITE

The study was performed in for leprosy endemic municipalities in the North and Northeast regions of the country, including Vitoria da Conquista and Anage (Bahia), Fortaleza and Sobral (Ceara); Olinda and Cabo de Santo Agostinho (Pernambuco); Mossoro (Rio Grande do Norte); Porto Velho and Cacoal (Rondonia) (Figure 1). These municipalities exhibit a diverse range of epidemiological, sociodemographic and economic characteristics. There are also differences in the structuring of health services for leprosy surveillance and diagnosis in each municipality, with different healthcare access barriers. (12,13)

There is a predominance of urban populations in all municipalities, with the exception of Anage, in Bahia, where approximately 80% of the population is concentrated in rural areas. Fortaleza, in Ceara, as well as Olinda, in Pernambuco, are urban cities and have a higher population density compared to the other municipalities.

Considering the dimensions of social and economic vulnerability, the study assessed income, poverty and inequality indicators that show significant differences among municipalities. Regarding the per capita income indicator, all municipalities, despite having a per capita household income greater than BRL 140 ($29), have a significant percentage of people living in poverty. The Gini index, or Gini coefficient, assesses income distribution across a population, indicating relative inequality in income distribution between municipalities; a high Gini Index indicates more inequality. In 2010, Fortaleza presented a low index of 0.61. However, according to data from the National Household Sample Survey (PNAD), the state of Rio Grande do Norte had the lowest index (0.59). The Municipal Human Development Index (MHDI) values are below the national average of 0.77 for the year 2021. (12,14)

The municipalities with the lowest Primary Health Care (PHC) coverage are Vitoria da Conquista--Bahia (2021: 57.8%), followed by Porto Velho--Rondonia (2021: 54.7%).

Only Anage does not have a referral centre for leprosy, and diagnosis and treatment are conducted at PHC level. (13)

PARTICIPANT SAMPLING, DATA COLLECTION, AND ANALYSIS

In order to identify the patients according to the selection criteria, we used the state-based leprosy data from the SINAN databases. Eligible participants were contacted via phone for a survey; up to three phone call attempts were made in different shifts when a call remained unanswered.

The protocol for data collection consisted of speaking exclusively with the person notified by the health services. This practice sought not only greater reliability of the data collected, but above all, was guaranteeing the ethical principles of diagnosis confidentiality. Telephone contacts were conducted by technically qualified researchers and health professionals which were trained on the study protocol and materials, in order to allow maximum standardization and quality of the approaches. The data collection period was from May to December 2020.

After the initial presentation, we proceeded to the detailed reading of the participant information and informed consent form (ICF), addressing the objectives of the study, its benefits, possible risks, the right to withdrawal, and the measures in addition to privacy and confidentiality such as pseudonymization. With all information available and potential questions from participants answered, individuals contacted decided whether or not to participate in the study The participant information and ICF were sent via email, and the informed consent was recorded. At the end of the data collection phase, all included individuals requiring specific care, as per the participants' expressed needs, were referred to reference health services in their area of residence.

Data collected were entered into the data management application Research Electronic Data Capture (REDCap), with subsequent extraction in the TabWin[R] 4.2 software, from the Department of Informatics of the Brazilian Unified Health System (DATASUS-MS). (15) The statistical analysis was performed using the STATA version 11 software package. In order to recognize health and social needs, we conducted a descriptive analysis of sociodemographic, clinical, and psychosocial variables. Subsequently, we tried to verify the existence of a possible association between these dimensions and loss of income through binary logistic regression analysis. Following this, univariate logistic regression analyses were conducted to identify possible associated factors. The statiscal test performed for this regression was the QI. (2) The odds ratio (OR) was calculated for each independent variable of the study, with the respective 95% confidence intervals (95%CI).

Ethics

This study was submitted to the Research Ethics Committee of the Federal University of Ceara and, subsequently, to the National Research Ethics Committee (CONEP), where ethics approval was obtained (number 4201,469). All procedures adopted during the study were developed based on Resolution CNS 466/12, 510/2016 and 292/99 of the National Health Council. As stated above, informed consent was obtained from participants and referrals to more specialized care were provided to participants if needed.

Results

According to the SINAN databases, 2,040 eligable leprosy patients were registered in the study settings in the study period. Patients with an incorrect phone number were excluded, which was 27.2% of the patients (n = 555/2040). The 1,485 remaining patients were aligned with eligibility criteria in different municipalities; among these 53.9% (n = 800/1485) of the people did not respond to any of the three telephone contact attempts performed in different shifts and were subsequently excluded; 22.8% (n = 339/1485) answered the call but refused to participate in the research. Thus, a total of 346 participants (23.2%; n = 346/1485) answered the call and consented to participate in this study (Flowchart 1).

Out of the total number of leprosy patients included in this study (n = 346), the majority were men (n = 189; 54.6%), of Pardo race (mixed-race Brazilians, a classification used by the

Brazilian Institute of Geography and Statistics) (n = 184; 53.2%), aged between 18 and 60 years (n = 262; 75.7%), with completed high school (n = 99; 28.6%) or basic education (n = 74; 21.4%), residing in urban areas (n = 316; 91.3%) in municipalities in the state of Ceara (n = 178; 51.4%). Most lived in their own house (n = 244; 70.5%), together with up to three household contacts (n = 218; 63%). Most participants used buses (public transport) as their main means of transportation (n = 161; 46.5%).

There was a higher frequency of people with multibacillary leprosy (70.5%; n = 244/346) and 38.1% (n = 132/346) had no disability at the time of diagnosis. Among the participants who were experiencing physical disability, 8.3% (n = 29/346) reported the existence of a grade 2 (visible) disability at time of diagnosis.

Interruption of MDT for leprosy occurred in 31.8% (n = 110/346) of the patients, and of these participants, 46.4% (n = 51/110) reported that the interruption was related to the Covid-19 pandemic. A percentage of 25.1% (n = 87/346) of the study population reported that they experienced a leprosy reaction, and 60.9% (n = 53/87) reported using specific medication for these exacerbation episodes.

A total of 14.1% (n = 49/346) of the included persons affected by leprosy recognized skin lesions with reduced sensitivity in some of their household contacts. However, a notable proportion of study participants (35.3%; n = 122/346) reported that no leprosy screening by health workers had been conducted for one or more household contacts. Among these, 12.2% (n = 15/122) reported the pandemic as main reason for the lacking examination of their contacts (Table 1).

When assessing mental wellbeing, onset or intensification of sadness was reported by 32.4% (n = 112/346) of the participants, fear by 35.5% (n = 123/346), sleep deprivation by 34.7% (n = 120/346), loss or increase in appetite by 17.0% (n = 59/346), and depression by 9.8% (n = 34/346) (Figure 2). "Feeling welcomed" during social distancing was reported by 76.9% (n = 266/346), and it was more frequent in people who were optimistic about the future (77.4%, n = 268/346). A percentage of 23.7 (n = 82/346) of people felt the need for professional psychological support and, at the time of the interview, 29.8% (n = 103/346) reported the need to be referred to a health unit because of health problems. We observed an association between a loss of income and sadness (OR 1.61; 95%CI 1.02-2.54; p-value 0.04) and self-reported depression (OR 2.35; 95%CI 1.11-4.98; p-value 0.03) (Table 2).

Social distancing related to the Covid-19 pandemic had a financial impact on 33.2% (n = 115/346) of the participants. Linked to this, 41.9% (n = 145/346) of the participants received emergency (Covid-19-related) benefits, which were initiated by the government in April 2020. There was an association between reduced income and access to the emergency Covid-19 benefits (OR 2.03; 95%CI 1.32-3.13; p-value 0.00). In addition, we also observed an association of participants experiencing a reduced income and having access to non-Covid-19 related government benefits (OR 0.56; 95%CI 0.36-0.86; p-value 0.01) with their work context being: unemployed (OR 3.29; 95%CI 1.68-6.46; p-value 0.00),self-employed (OR 2.87; 95%CI 1.36-6.09; p-value 0.01) or an informal worker (OR 6.48; 95%CI 1.68-27.21; p-value 0.01) (Table 3).

Discussion

The present study shares perspectives about the psychosocial and health status as well as about health needs of people with leprosy, during the period of social distancing as a result of the Covid-19 pandemic in vulnerable regions of Brazil. MDT interruptions, feelings of sadness, and increased economic difficulties were reported by the study participants. The significant association of loss of income and sadness, need for care in health services, need to access income redistribution programs, being unemployed or self-employed or having informal work, reaffirm the close relationship between health and socioeconomic status. These are aspects that are even more relevant for people affected by neglected tropical diseases (NTDs), compared to healthy populations, as they are often already marginalized. (16)

Leprosy is a chronic condition which can cause permanent physical disability and is linked with stigma and discrimination. Persons affected by leprosy often need longitudinal care, including the use of MDT, self-care for disability prevention, access to physiotherapy, orthoses and prostheses, psychological care and occupational therapy. The possibility of leprosy reactions affects clinical management, often requiring emergency pain control, nerve assessments, and the use of corticosteroids and other immunosuppressants. In these cases, failure to intervene appropriately in reference services can lead to potentially irreversible nerve damage and subsequently disabilities. (8,17,18) In addition, screening contacts of leprosy patients and initiating early treatment in newly diagnosed patients is crucial to hinder disease transmission and prevent disabilities. Other studies also recognized increased barriers in healthcare access for persons affected by leprosy during the Covid-19 pandemic, increasing health inequity. (10,19-22) Therefore, the discontinuity in patient and contact follow-up as well as the MDT interruptions which were reported by more than 30% of the participants in this study are important to address to relevant stakeholders in leprosy control. As the Covid-19 pandemic has currently abated, health services should prioritize the resumption of leprosy treatment, evaluation and prevention of new nerve damage and provision of psychosocial care. (19,23) Pharmacies within the healthcare network experienced a shortage of MDT availability, contributing to the temporary interruption of treatment for patients. (24,25) Improved supply chain management, considering risk mitigation, is therefore advised.

In addition, the surveillance of household contacts represents another key issue for the control of leprosy. (26) However, in this study, over 35% of contacts of leprosy patients undergoing treatment were not evaluated, while they have an increased risk for developing the disease. In addition, participants stated that many of these contacts experienced clinical signs/symptoms suggestive for the disease. Failures in contact surveillance, leading to delays in early diagnosis and treatment provision, result in a higher individual disease burden, potential disabilities, and sustained transmission of Mycobacterium leprae. (27)

Data from the Brazilian Ministry of Health indicate a significant decrease in the diagnosis of newly diagnosed leprosy cases from 2019 (27,864) to 2020 (17,979), likely associated with limitations in the operational capacity of healthcare teams responsible for leprosy control, especially within primary healthcare settings, amid the Covid-19 pandemic. (28) During the pandemic, health staff were transferred to Covid-19 related health services. (29) This task-shifting process could be a significant factor contributing to the decreased number of contacts undergoing leprosy screening during the pandemic. Providing leprosy post-exposure prophylaxis (PEP) with a single dose of rifampicin (SDR) is not yet a standard component of leprosy control in Brazil. Consequently, it is imperative to mobilize health managers, professionals, and society to resume progress in contact screening. Ideally, this should also be combined with the provision of chemoprophylaxis (SDR-PEP), as outlined in the 2018 WHO "Guidelines for the diagnosis, treatment and prevention of leprosy", in the 2020 WHO Technical Guidance on "Contact tracing and post-exposure prophylaxis" and as advocated for in the second pillar of the 2020-2030 global WHO leprosy strategy. (48-50)

Feelings of sadness and fear, and changes in sleeping and eating patterns were mentioned by almost 40% of the leprosy patients in this study. Due to affected mental health secondary to the disease, psychosocial care is required both in the PHC setting and in the psychosocial care network. Literature confirms that individuals who underwent social distancing because of the Covid-19 pandamic were generally more prone to experiencing mental health problems as feelings of deprivation and social restraint lead to stress, anxiety, and depression. (30)

This aspect has considerable relevance for leprosy. We emphasize the significance of historical, social, and cultural factors associated with the context of social distancing, segregation, and stigma experienced by thousands of people with leprosy in Brazil. Persons affected by leprosy and the Covid-19 pandemic therefore face intersecting challenges related to stigma, discrimination, and social isolation. Strategies to reduce psychological suffering and providing psychological support to this group should be considered a priority. (30,31)

Through the telephone calls made for this study, besides collecting data, it was noticed that listening to the participants also resulted in people feeling heard, providing a level of support. Altaf described similar findings in her scientific work, explaining that extremely impoverished people desire both mental and physical human contact and respect, which can be achieved by listening to them and taking their stories seriously. (32) Good-quality listening can build confidence in the person sharing her/his story. This is especially important for persons affected by leprosy who are frequently experiencing low self-esteem, stigmatisation and isolation. (33) This does often not require a psychologist, which are not always available, but can also be reached by e.g. peer support or other forms of informal psychological care. (32,34)

Additionally, we referred people to health services according to the reported needs during the telephone call. (32) This showed that phone-calls, contact via mobile phone messenger apps or other forms of telemedicine, could potentially contribute to meet certain health demands of persons affected by leprosy. (21,35) Innovative approaches such as telemedicine, when carefully planned and implemented, have the potential to increase the access to healthcare services, integrate remote regions, and overcome the challenges faced by universal healthcare systems in countries with vast territorial dimensions like Brazil. (36) The experiences gained during the Covid-19 pandemic regarding remote service delivery reinforced these possibilities. (21,37)

We observed various instances of social vulnerability of the people participating in the study. The majority of participants were paid workers, but over 30% were unemployed, and more than 40% were eligible for governmental (emergency) benefits, indicating significant financial strain during the pandemic, particularly among those who were unemployed, self-employed, or engaged in informal work. The established association between leprosy and impoverished living condition, as recognized in scientific literature, reinforces the conclusions of this study and underscores the complex interplay of social determinants of health. (31,38,39)

Similarly, the pandemic has worsened the circ*mstances of poverty and extreme poverty that were already prevalent in the country since the financial and political crises that struck Brazil in 2016, which also affected health services. (22,23,10,19,21,24) This has widened the gap between the current reality in Brazil and the targets set by the WHO for 2030 in controlling Neglected Tropical Diseases (NTDs), which include reducing the number of patients requiring medication by 90% within the next seven year. (26) To still reach this goal, increased integrated care and surveillance is necessary, also focusing on the (geographical) context of people at risk. (7,26,40)

This study has some limitations that may have an impact on the results presented. A relatively large number (53.8%) of registered new leprosy patients could not be reached as no up-to-date telephone numbers were available. In addition, many people refused (22.8%) to participate in the research. For future studies on this topic, it may be interesting to additionally collect qualitative data via semi-structured/open interviews, creating more in-depth understanding of the impact of Covid-19 for persons affected by leprosy or other NTDs. Additionally, it would be interesting to also investigate the perspective from policymakers in the health sector, as well as from health staff.

Conclusion

The pandemic had significant economic, social, mental and physical health impact, further challenging leprosy control. Furthermore, the economic fallout from Covid-19, leading to decreased income for thousands of families and a subsequent rise in poverty levels, necessitates a holistic approach. Comprehensive, multisectoral, and integrated policies are needed to promote social justice, particularly for vulnerable groups such as persons affected by leprosy and their families. (8)

Interruption of MDT, psychological suffering, failures in the surveillance of contacts of leprosy patients, and adverse financial repercussions for those affected by leprosy were experienced during the pandemic. Similar findings were described by Silva da Paz et al. and Silva Matos et al. for the Brazilian context, as well as by WHO. (41,42,43)

At a health system level, the Covid-19 pandemic has led to a necessary reallocation of resources due to the urgent nature of the situation. However, as also described by Roadevin and Hill, it is crucial not to overlook the long-term consequences on other health issues. (44) Vulnerable patient groups, including those affected by NTDs, are adversely affected when resources are redirected to pandemic-related services. Consequently, policymakers must carefully consider the impact of shifted healthcare resources on different population groups. In 2022, the WHO introduced a new strategy aimed at enhancing preparedness for pandemics and epidemics. (45) It includes three fundamental pillars: (1) trust (2) solidarity and equity and, (3) sustainable development. The authors of this article see a clear overlap between these values and the principles needed for successful leprosy control. Health services should incorporate lessons learned from the past pandemic, enhancing preparedness and strengthening the resilience of the overall healthcare delivery system, given the likelihood of future pandemics or other crises emerging. (46,47)

Therefore, there is a pressing need to reinstate efforts aimed at monitoring persons affected by leprosy. Additionally, it is essential to implement location-specific strategies to foster adherence to clinical treatment, facilitate physical rehabilitation, while also supporting mental well-being. Similarly, there is a need to develop and invest in new strategies aimed at expanding the coverage and improving the quality of surveillance of patients' contacts. WHO recommends to implement contact screening combined with chemoprophylaxis using single-dose rifampicin, (48,49) to accelerate the reduction in the number of newly diagnosed leprosy patients and hinder the transmission of Mycobacterium leprae. (50) Lastly, promoting social participation and inclusion of persons affected by leprosy is vital for improving mental wellbeing and reducing social inequalities. These are essential requirements for addressing health and social justice, as emphasized by the United Nations Sustainable Development Goals. (51)

Authors' contribution

AMdR, EAdS: conceptualization of the study design, data analysis and interpretation, preparation of the manuscript. AFF: data analysis and interpretation. NNLF, AdSdR, ARdA: conceptualization of the study design, data collection and analysis. RdAS: conceptualization of the study design. AS, ANRj: critical review of the data collected and manuscript. JAdMS: conceptualization of the research design and study design, critical review of the data collected and manuscript.

Acknowledgement

We extend our deepest sympathies to the family, friends and colleagues of Rejane de Almeida Silva, who tragically passed away due to COVID-19 during the course of this study. Her invaluable contributions will be forever appreciated and remembered. Additionally, we extend our sincere gratitude to all persons affected by leprosy who participated in this study for sharing their experiences.

Funding source

Funded by NHR Brazil, NLR Alliance.

Conflict of interests

The authors declare no conflicts of interest.

doi: 10.47276/lr.95.1.97

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Aymee Medeiros da Rocha (a,b), Eliana Amorim de Souza (a,c), Anderson Fuentes Ferreira (b), Nagila Nathaly Lima Ferreira (a,b), Adriana da Silva dos Reis (a), Antonio Reldismar de Andrade (d), Rejane de Almeida Silva (a), Anne Schoenmakers (f,g), Alberto Novaes Ramos Jr (b,e) & Jose Alexandre Menezes da Silva (a)

(a) NHR Brazil, Fortaleza, Ceara, Brazil ORCIDs: https://orcid.org/0000-0002-9761-2403; https://orcid.org/0000-0002-9653-3164; https://orcid.org/0000-0002-1261-630X; https://orcid.org/ 0000-0002-5397-1279; https://orcid.org/0000-0003-4603-978X

(b) Graduate Program in Public Health, School of Medicine, Federal University of Ceara, Fortaleza, Ceara, Brazil ORCIDs: https://orcid.org/0000-0002-1816-9459; https://orcid.org/0000-0 001-7982-1757

(c) Epidemiology and Collective Health Department, Multidisciplinary Health Institute, Federal University of Bahia--Campus Amsio Teixeira, Vitoria da Conquista, Bahia, Brazil

(d) Health District VII, Health Department of Recife, Brazil ORCID: https://orcid.org/0000-0001-9605-5468

(e) Department of Community Health, School of Medicine, Federal University of Ceara, Brazil

(f) NLR International, Netherlands ORCID: https://orcid.org/0000-0003-3040-7883

(g) Erasmus MC, University Medical Center Rotterdam, Netherlands

Submitted 26 August 2023; Accepted 14 February 2024

Correspondence to: Aymee Medeiros da Rocha, Avenida Desembargador Moreira, 2001, Salas 806 and 807, Bairro: Aldeota, CEP: 60170-001, Fortaleza, Ceara, Brazil. (Tel.: +55 (85) 3055-4133; e-mail: [emailprotected])

Caption: Figure 1. Study site: (A) States studied, (B) Municipalities of Rondonia, (C) Municipalities of Ceara, (D) Municipalities of Pernambuco, (E) Municipalities of Rio Grande do Norte, (F) Municipalities of Bahia, 2022.

Caption: Flowchart 1. Flowchart of study population enrollment from Notifiable Diseases Information System (SINAN)

Table 1. Social and clinical characteristics of people undergoingtreatment for leprosy during the Covid-19 pandemic and loss ofincome of residents of municipalities in the North and Northeastregions in 2020 Loss of incomeVariable Total % No % Yes %Total 346 100 176 50.9 170 49.1Sex Man 189 54.6 97 55.1 92 54.1 Woman 157 45.4 79 44.9 78 45.9 Missing data 0 0.0 0 0.0 0 0.0Race/color according to BIGS White 62 17.9 31 17.6 31 18.2 Black 68 19.7 35 19.9 33 19.4 Asian 5 1.5 3 1.7 2 1.2 Pardo 184 53.2 99 56.3 85 50 Indigenous 2 0.6 0 0 2 1.2 Missing data 25 7.2 8 4.5 17 10.0Age group 18-60 262 75.7 130 73.9 132 77.6 >60 84 24.3 46 26.1 38 22.4 Missing data 0 0.0 0 0.0 0 0.0Education Illiterate 36 10.4 22 12.5 14 8.2 Basic education 74 21.4 40 22.7 34 20.0 Elementary school 63 18.2 28 15.9 35 20.6 High school 99 28.6 45 25.6 54 31.8 University education 54 15.6 32 18.2 22 12.9 Missing data 20 5.8 9 5.1 11 6.5State of residence Bahia 10 2.9 3 1.7 7 4.1 Ceara 178 51.4 85 48.3 93 54.7 Pernambuco 110 31.8 58 33.0 52 30.6 Rio Grande do Norte 19 5.5 13 7.4 6 3.5 Rondonia 29 8.4 17 9.7 12 7.1 Missing data 0 0.0 0 0.0 0 0.0Area of residence Urban 316 91.3 158 89.8 158 92.9 Rural 21 6.1 12 6.8 9 5.3 Missing data 9 2.6 6 3.4 3 1.8Own home No 102 29.5 52 29.5 50 29.4 Yes 244 70.5 124 70.5 120 70.6 Missing data 0 0.0 0 0.0 0 0.0Number of households 1 to 3 218 63.0 119 67.6 99 58.2 >3 128 37.0 57 32.4 71 41.8 Missing data 0 0.0 0 0.0 0 0.0Means of transport Car 89 25.7 51 29.0 38 22.4 Bicycle 30 8.7 11 6.3 19 11.2 Motorcycle 36 10.4 20 11.4 16 9.4 Taxi/Uber 20 5.8 10 5.7 10 5.9 Bus 161 46.5 77 43.8 84 49.4 Other 8 2.3 6 3.4 2 1.2 Missing data 2 0.6 1 0.5 1 0.5Operational classification Paucibacillary 99 28.6 49 27.8 50 29.4 Multibacillary 247 71.4 127 72.2 120 70.6 Missing data 0 0.0 0 0.0 0 0.0Degree of disability in thediagnosis Grade 0 120 34.7 62 35.2 58 34.1 Grade 1 50 14.5 23 13.1 27 15.9 Grade 2 29 8.38 11 6.25 18 10.6 Unknown 132 38.2 72 40.9 60 35.3 Missing data 15 4.2 8 4.6 7 4.1Interrupted MDT No 236 68.2 128 72.7 108 63.5 Yes 110 31.8 48 27.3 62 36.5 Missing data 0 0.0 0 0.0 0 0.0Presence of leprosy reaction No 245 70.8 122 69.3 123 72.4 Yes 87 25.1 46 26.1 41 24.1 Does not know and/or does 14 4.1 8 4.6 6 3.5 not want to answer Missing data 0 0.0 0 0.0 0 0.0Use of medication for leprosyreaction No 35 39.8 20 11.4 15 00 CO Yes 53 60.2 27 15.3 26 15.3 Missing data 258 0.0 129 73.3 129 75.9Contacts with skin lesions withaltered sensitivity No 296 85.5 155 88.1 141 82.9 Yes 49 14.2 21 11.9 28 16.5 Missing data 1 0.3 0 0.0 1 0.6Contacts evaluated by healthprofessionals No 122 35.3 66 37.5 56 32.9 Yes, all household 180 52.0 84 47.7 96 56.5 contacts Yes, some household 39 11.3 23 13.1 16 9.4 contacts Missing data 5 1.4 3 1.7 2 1.2Variable Odds 95%CI p- ratio valueTotalSex Man 1 Woman 1.04 0.68 1.59 0.85 Missing data --Race/color according to BIGS White 1 Black 0.94 0.47 1.88 0.87 Asian 0.67 0.10 4.27 0.67 Pardo 0.86 0.48 1.53 0.60 Indigenous -- Missing dataAge group 18-60 1 >60 0.81 0.50 1.33 0.41 Missing data --Education Illiterate 1 Basic education 1.34 0.59 3.01 0.48 Elementary school 1.96 0.85 4.52 0.11 High school 1.89 0.87 4.11 0.11 University education 1.08 0.46 2.56 0.86 Missing data --State of residence Bahia 1 Ceara 0.47 0.12 1.87 0.28 Pernambuco 0.38 0.09 1.56 0.18 Rio Grande do Norte 0.20 0.04 1.04 0.06 Rondonia 0.30 0.06 1.41 0.13 Missing data --Area of residence Urban 1 Rural 0.75 0.31 1.83 0.53 Missing data --Own home No 1 Yes 1.01 0.63 1.60 0.98 Missing data -Number of households 1 to 3 1 >3 1.50 0.97 2.32 0.07 Missing data --Means of transport Car 1 Bicycle 2.32 0.99 5.44 0.05 Motorcycle 1.07 0.49 2.34 0.86 Taxi/Uber 1.34 0.51 3.55 0.55 Bus 1.46 0.87 2.47 0.15 Other 0.45 0.09 2.34 0.34 Missing data --Operational classification Paucibacillary 1 Multibacillary 0.93 0.58 1.48 0.75 Missing data --Degree of disability in thediagnosis Grade 0 1 Grade 1 1.25 0.65 2.43 0.50 Grade 2 1.75 0.76 4.02 0.19 Unknown 0.89 0.54 1.46 0.65 Missing data --Interrupted MDT No 1 Yes 1.53 0.97 2.41 0.07 Missing data --Presence of leprosy reaction No 1 Yes 0.88 0.54 1.44 0.62 Does not know and/or does 0.74 0.25 2.21 0.59 not want to answer Missing data --Use of medication for leprosyreaction No 1 Yes 1.28 0.54 3.03 0.57 Missing data --Contacts with skin lesions withaltered sensitivity No 1 Yes 1.47 0.80 2.70 0.22 Missing data --Contacts evaluated by healthprofessionals No 1 Yes, all household 1.35 0.85 2.14 0.21 contacts Yes, some household 0.82 0.39 1.70 0.59 contacts Missing data ---- Not calculated. Abbreviations: BIGS = Brazilian Institute ofGeography and Statistics, CI = confidence interval, MDT = multidrugtherapy.

Table 2. Data on income loss and the relation to psychosocialvariables of adults undergoing leprosy treatment in the Covid-19pandemic in the North and Northeast regions in Brazil Loss of incomeVariable Total % No % Yes %Total 346 100 176 170 49.1Onset or intensification ofsadness No 234 67.6 128 106 62.4 Yes 112 32.4 48 0.0 64 37.6 Missing data 0 0.0 0 0 0.0Onset or intensification offear No 223 64.5 119 104 61.2 Yes 123 35.5 57 0.2 66 38.8 Missing data 0 0.0 0 0 0.0Onset or intensification ofsleep loss No 226 65.3 123 103 60.6 Yes 120 34.7 53 0.1 67 39.4 Missing data 0 0.0 0 0 0.0Onset or intensification ofincrease or loss of appetite No 287 82.9 150 137 80.6 Yes 59 17.1 26 0.3 33 19.4 Missing data 0 0.0 0 0 0.0Depression (self-reported) No 312 90.2 165 147 86.5 Yes 34 9.8 11 0.0 23 13.5 Missing data 0 0.0 0 0 0.0Feeling welcome in socialdistancing context No 79 22.8 34 45 26.5 Yes 266 76.9 141 0.1 125 73.5 Missing data 1 0.3 1 0 0.0Optimistic about thefuture No 58 16.8 28 30 17.6 Yes 268 77.5 140 0.6 128 75.3 Missing data 20 5.7 8 12 7.1Felt in need of professional(psychological) help No 260 75.1 139 121 71.2 Yes 82 23.7 34 0.1 48 28.2 Missing data 4 1.2 3 1 0.6Reported need for referralto a health unit No 242 69.9 132 75.0 110 64.7 Yes 103 29.8 43 24.4 60 35.3 Missing data 1 0.3 1 0.6 0 0.0Variable Odds 95%CI p- ratio valueTotal --Onset or intensification ofsadness No 1 Yes 1.61 1.02 2.54 0.04 Missing data --Onset or intensification offear No 1 Yes 1.32 0.85 2.06 0.21 Missing data --Onset or intensification ofsleep loss No 1 Yes 1.51 0.97 2.36 0.07 Missing data --Onset or intensification ofincrease or loss of appetite No 1 Yes 1.39 0.79 2.44 0.25 Missing data --Depression (self-reported) No 1 Yes 2.35 1.11 4.98 0.03 Missing data --Feeling welcome in socialdistancing context No 1 Yes 0.67 0.40 1.11 0.12 Missing data --Optimistic about thefuture No 1 Yes 0.85 0.48 1.51 0.58 Missing data --Felt in need of professional(psychological) help No 1 Yes 1.62 0.98 2.68 0.06 Missing data --Reported need for referralto a health unit No 1 Yes 1.67 1.05 2.67 0.03 Missing data ---- Not calculated. Abbreviation: CI = confidence interval.

Table 3. Income forms in relation to income variables of peopleundergoing leprosy treatment in municipalities in the North andNortheast regions in Brazil in the Covid-19 pandemic Loss of incomeVariable Total % No % Yes %Total 346 100 176 50.9 170 49.1Emergency Covid-19government benefits No 201 58.1 117 66.5 84 49.4 Yes 145 41.9 59 33.5 86 50.6 Missing data 0 0.0 0 0.0 0 0.0Other governmentbenefits No 214 61.8 97 55.1 117 68.8 Yes 132 38.2 79 44.9 53 31.2 Missing data 0 0.0 0 0.0 0 0.0Benefits Social welfare program 31 9.0 17 9.7 14 8.2Bolsa Familia Beneficiary pension 9 2.6 5 2.8 4 2.4 Retirement pension 57 16.5 37 21 20 11.8 Paid sick leave 20 5.8 12 6.8 8 4.7 Other 14 4.1 7 4.0 7 4.1 Missing data 215 62.1 98 55.7 117 68.8Work situation Formal employee 54 15.6 35 19.9 19 11.2 Unemployed 117 33.8 42 23.9 75 44.1 Self-employed 64 18.5 25 14.2 39 22.9 Informal worker 14 4.1 3 1.7 11 6.5 Civil servant 16 4.6 16 9.1 0 0 Retiree 74 21.4 49 27.8 25 14.7 Missing data 7 2.0 6 3.4 1 0.6Worker: reduction insalary/remuneration No 44 12.7 33 18.8 11 6.5 Yes 9 2.6 2 1.14 7 4.1 Missing data 293 84.7 141 80.1 152 89.4Variable Odds 95%CI p- ratio valueTotal --Emergency Covid-19government benefits No 1 Yes 2.03 1.32 3.13 0.00 Missing data --Other governmentbenefits No Yes 0.56 0.36 0.86 0.01 Missing data --Benefits Social welfare program 1Bolsa Familia Beneficiary pension 0.97 0.22 4.32 0.97 Retirement pension 0.66 0.27 1.60 0.36 Paid sick leave 0.81 0.26 2.53 0.72 Other 1.21 0.34 4.30 0.76 Missing data --Work situation Formal employee 1 Unemployed 3.29 1.68 6.46 0.00 Self-employed 2.87 1.36 6.09 0.01 Informal worker 6.75 1.68 27.21 0.01 Civil servant -- Retiree 0.94 0.45 1.97 0.87 Missing data --Worker: reduction insalary/remuneration No 1 Yes 10.50 1.89 58.24 0.01 Missing data ---- Not calculated. Abbreviation: CI = confidence interval.

Figure 2. Psychosocial needs reported by adults undergoing treatmentfor leprosy, residing in municipalities in the North and Northeastregions in Brazil in the Covid-19 pandemicSocial impactdue to socialdistancing 36.4ExtremeFear 35.6SleepLoss 34.7ExtremeSadness 32.4Loss orincreaseof appetite 17.1Depression 9.8Note: Table made from bar graph.

Aymee Medeiros da Rocha ORCID: https://orcid.org/0000-0002-9761-2403

Aymee Medeiros da Rocha ORCID: https://orcid.org/0000-0002-9653-3164

Aymee Medeiros da Rocha ORCID: https://orcid.org/0000-0002-1261-630X

Aymee Medeiros da Rocha ORCID: https://orcid.org/0000-0002-5397-1279

Aymee Medeiros da Rocha ORCID: https://orcid.org/0000-0003-4603-978X

Aymee Medeiros da Rocha ORCID: https://orcid.org/0000-0002-1816-9459

Aymee Medeiros da Rocha ORCID: https://orcid.org/0000-0001-7982-1757

Eliana Amorim de Souza ORCID: https://orcid.org/0000-0002-9761-2403

Eliana Amorim de Souza ORCID: https://orcid.org/0000-0002-9653-3164

Eliana Amorim de Souza ORCID: https://orcid.org/0000-0002-1261-630X

Eliana Amorim de Souza ORCID: https://orcid.org/0000-0002-5397-1279

Eliana Amorim de Souza ORCID: https://orcid.org/0000-0003-4603-978X

Anderson Fuentes Ferreira ORCID: https://orcid.org/0000-0002-1816-9459

Anderson Fuentes Ferreira ORCID: https://orcid.org/0000-0001-7982-1757

Nagila Nathaly Lima Ferreira ORCID: https://orcid.org/0000-0002-9761-2403

Nagila Nathaly Lima Ferreira ORCID: https://orcid.org/0000-0002-9653-3164

Nagila Nathaly Lima Ferreira ORCID: https://orcid.org/0000-0002-1261-630X

Nagila Nathaly Lima Ferreira ORCID: https://orcid.org/0000-0002-5397-1279

Nagila Nathaly Lima Ferreira ORCID: https://orcid.org/0000-0003-4603-978X

Nagila Nathaly Lima Ferreira ORCID: https://orcid.org/0000-0002-1816-9459

Nagila Nathaly Lima Ferreira ORCID: https://orcid.org/0000-0001-7982-1757

Adriana da Silva dos Reis ORCID: https://orcid.org/0000-0002-9761-2403

Adriana da Silva dos Reis ORCID: https://orcid.org/0000-0002-9653-3164

Adriana da Silva dos Reis ORCID: https://orcid.org/0000-0002-1261-630X

Adriana da Silva dos Reis ORCID: https://orcid.org/0000-0002-5397-1279

Adriana da Silva dos Reis ORCID: https://orcid.org/0000-0003-4603-978X

Antonio Reldismar de Andrade ORCID: https://orcid.org/0000-0001-9605-5468

Rejane de Almeida Silva ORCID: https://orcid.org/0000-0002-9761-2403

Rejane de Almeida Silva ORCID: https://orcid.org/0000-0002-9653-3164

Rejane de Almeida Silva ORCID: https://orcid.org/0000-0002-1261-630X

Rejane de Almeida Silva ORCID: https://orcid.org/0000-0002-5397-1279

Rejane de Almeida Silva ORCID: https://orcid.org/0000-0003-4603-978X

Anne Schoenmakers ORCID: https://orcid.org/0000-0003-3040-7883

Alberto Novaes Ramos Jr ORCID: https://orcid.org/0000-0002-1816-9459

Alberto Novaes Ramos Jr ORCID: https://orcid.org/0000-0001-7982-1757

Jose Alexandre Menezes da Silva ORCID: https://orcid.org/0000-0002-9761-2403

Jose Alexandre Menezes da Silva ORCID: https://orcid.org/0000-0002-9653-3164

Jose Alexandre Menezes da Silva ORCID: https://orcid.org/0000-0002-1261-630X

Jose Alexandre Menezes da Silva ORCID: https://orcid.org/0000-0002-5397-1279

Jose Alexandre Menezes da Silva ORCID: https://orcid.org/0000-0003-4603-978X