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Background Although leprosy is largely curable with multidrug therapy, incomplete treatment limits therapeutic effectiveness and is an important obstacle to disease control. To inform efforts to improve treatment completion rates, we aimed to identify the geographic and socioeconomic factors associated with leprosy treatment default in Brazil. Methodology/Principal findings Using individual participant data collected in the Brazilian national registries for social programs and notifiable diseases and linked as part of the 100 Million Brazilian Cohort, we evaluated the odds of treatment default among 20,063 leprosy cases diagnosed and followed up between 2007 and 2014. We investigated geographic and socioeconomic risk factors using a multivariate hierarchical analysis and carried out additional stratified analyses by leprosy subtype and geographic region. Over the duration of follow-up, 1,011 (5.0%) leprosy cases were observed to default from treatment. Treatment default was markedly increased among leprosy cases residing in the North (OR = 1.57; 95%CI 1.25–1.97) and Northeast (OR = 1.44; 95%CI 1.17–1.78) regions of Brazil. The odds of default were also higher among cases with black ethnicity (OR = 1.29; 95%CI 1.01–1.69), no income (OR = 1.41; 95%CI 1.07–1.86), familial income ≤ 0.25 times Brazilian minimum wage (OR = 1.42; 95%CI 1.13–1.77), informal home lighting/no electricity supply (OR = 1.53; 95%CI 1.28–1.82), and household density of > 1 individual per room (OR = 1.35; 95%CI 1.10–1.66). Conclusions The findings of the study indicate that the frequency of leprosy treatment default varies regionally in Brazil and provide new evidence that adverse socioeconomic conditions may represent important barriers to leprosy treatment completion. These findings suggest that interventions to address socioeconomic deprivation, along with continued efforts to improve access to care, have the potential to improve leprosy treatment outcomes and disease control., Author summary While the leprosy new case detection has been decreasing worldwide since the introduction of multidrug therapy (MDT) in the 1980s, treatment default remains an important risk factor for leprosy-associated disability and an obstacle to disease control and elimination. Treatment default occurs when an individual with leprosy does not take the prescribed number of doses required for treatment with MDT. We hypothesized that the frequency of defaulting may be influenced by geographic factors, especially as related to access to care, and socioeconomic factors, such as income, education, and household living conditions. To test this hypothesis, we investigated geographic and socioeconomic factors associated with leprosy treatment default among 20,063 new leprosy cases followed as part of the 100 Million Brazilian Cohort between 2007 and 2014. In total, 5.0% of the leprosy patients defaulted from MDT. Among the associated factors, we found that having residency in the North and Northeast of Brazil, black ethnicity, low familial income, lack of formal electricity, and a high household density were associated with higher odds of leprosy treatment default. Overall, these findings highlight the need for tailoring MDT strategies for vulnerable populations in high-burden communities and suggest that social policies aiming to alleviate poverty should be investigated as potential tools for improving leprosy treatment completion.

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003-2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage.

Background Brazil is the only country in Latin America that has adopted a national health system. This causes differences in access to health among Latin American countries and induces noticeable migration to Brazilian regions to seek healthcare. This phenomenon has led to difficulties in the control and elimination of diseases related to poverty, such as leprosy. The aim of this study was to evaluate social determinants and their relationship with the risk of leprosy, as well as to examine the temporal trend of its occurrence in a Brazilian municipality located on the tri-border area between Brazil, Paraguay and Argentina. Methods This ecological study investigated newly-diagnosed cases of leprosy between 2003 and 2015. Exploratory analysis of the data was performed through descriptive statistics. For spatial analysis, geocoding of the data was performed using spatial scan statistic techniques to obtain the Relative Risk (RR) for each census tract, with their respective 95% confidence intervals calculated. The Bivariate Moran I test, Ordinary Least Squares (OLS) and Geographically Weighted Regression (GWR) models were applied to analyze the spatial relationships of social determinants and leprosy risk. The temporal trend of the annual coefficient of new cases was obtained through the Prais-Winsten regression. A standard error of 5% was considered statistically significant (p < 0.05). Results Of the 840 new cases identified in the study, there was a predominance of females (n = 427, 50.8%), of white race/color (n = 685, 81.6%), age range 15 to 59 years (n = 624, 74.3%), and incomplete elementary education (n = 504, 60.0%). The results obtained from multivariate analysis revealed that the proportion of households with monthly nominal household income per capita greater than 1 minimum wage (β = 0.025, p = 0.036) and people of brown race (β = -0.101, p = 0.024) were statistically-significantly associated with risk of illness due to leprosy. These results also confirmed that social determinants and risk of leprosy were significantly spatially non-stationary. Regarding the temporal trend, a decrease of 4% (95% CI [-0.053, -0.033], p = 0.000) per year was observed in the rate of detection of new cases of leprosy. Conclusion The social determinants income and race/color were associated with the risk of leprosy. The study’s highlighting of these social determinants can contribute to the development of public policies directed toward the elimination of leprosy in the border region., Author summary The World Health Organization considers Brazil to be a priority country for the control of leprosy. This is determined by the high rates of prevalence, detection of new cases and proportion of cases in females, proportion of cases in children, and people with degree of incapacity II. Moreover, Brazil has been unable to achieve the target of one case per 10,000 inhabitants, despite efforts to eliminate the disease. Elimination and control become even more complex challenges in border regions if we consider the heavy flow of people between countries and the resulting overload for the local health system. Thus, this study aimed to identify the risk of leprosy and its social determinants, as well as to investigate the temporal trend of the disease in a region with a triple border, connecting Brazil, Paraguay and Argentina. We identified 840 new cases in the study; there was a predominance of women (n = 427, 50.8%), of white race/color (n = 685, 81.6%), age range 15 to 59 years (n = 624, 74.3%), with incomplete elementary education (n = 504, 60.0%). The social determinants income and race/color were associated with the risk of leprosy. The results may contribute to the planning of actions in health for border regions.