https://orcid.org/0000-0001-6951-186X
Figures
Abstract
Background
Disability due to leprosy in Colombia is a neglected public health problem. This work aims to describe the magnitude of leprosy in Colombia, the spatiotemporal distribution of the disability and explore the potential relationship between individual and treatment delay characteristics with degrees of disability.
Methods
Official leprosy data in Colombia between 2007 and 2020 were analyzed. The distribution of the grade 2 disability (G2D) rate was estimated. A Poisson spatiotemporal model was constructed to form clusters of municipalities with risk of G2D. A multinomial logistic regression model was used to quantify the relationships between patient characteristics and disability grades 1 (G1D) and 2 (G2D).
Results
During the fourteen-year period, 5240 leprosy cases were registered (median age: 51 years, IQR: 35–63), of which 63.8% (n = 3341) were men. The proportion of multibacillary forms was 65.9% (n = 3453), 47.1% (n = 2468) for grade 0 disability (G0D), 18.4% (n = 966) for G1D and 9.7% (n = 507) for G2D. Three clusters and 10 municipalities were detected for the municipal rate of G2D. The national rate of G2D ranged between 0.03/100,000 inhabitants in 2010 and 0.05/100,000 inhabitants in 2020. The prevalence ratio of G1D and G2D was significant in individuals aged 60 years or older, men, from the subsidized or uninsured health system, who had relapses, multibacillary type and in whom the delay between the onset of symptoms and treatment was 7–12 years.
Conclusion
In the context of leprosy elimination in Colombia, the prevalence of disability is high and heterogeneous in time and space. It is recommended to coordinate the necessary actions to “revitalize” the active epidemiological surveillance in the prioritized municipalities and strengthen the program including improving early detection, treatment and individual follow-up of patients with disabilities.
Author summary
Leprosy is a global public health challenge due to its risk of disability. Although Colombia has achieved elimination status and disease indicators have remained stable, leprosy remains a neglected disease. In this study, we described the characteristics of patients with leprosy and the spatiotemporal evolution of the most severe disability from Colombia. Our findings show that its presence in the country is persistent and that the degree of disability varies considerably by region. From the analysis, we identified concerning patterns in the rate of grade 2 disability (i.e., visible deformities), highlighting the need to improve access to early diagnosis and strengthen prevention strategies. In this research, we seek to provide key information to optimize epidemiological surveillance programs and reduce disease-related complications, contribute to knowledge about leprosy in Colombia, and provide evidence to refine prevention and treatment strategies, in order to mitigate the impact of the disease on affected communities.
Citation: Arango-Úsuga C, Ochoa J, Hincapié-Palacio D, León A (2025) Endemicity, disability and neglect: Leprosy in Colombia 2007–2020. PLoS Negl Trop Dis 19(9): e0013514. https://doi.org/10.1371/journal.pntd.0013514
Editor: Michael Marks, London School of Hygiene and Tropical Medicine, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
Received: June 13, 2025; Accepted: September 1, 2025; Published: September 22, 2025
Copyright: © 2025 Arango-Úsuga et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: This study used national datasets obtained from the National Public Health Surveillance System of Colombia (SIVIGILA, by its Spanish acronym). The data were anonymized and de-identified prior to use, following a formal request process in compliance with applicable regulations. Due to confidentiality agreements and legal restrictions, we are not permitted to share the raw data publicly. Interested researchers may request access to these data through the Colombian National Institute of Health (INS, by its Spanish acronym) at https://www.ins.gov.co, subject to institutional approval. Population denominator data for the calculation of grade 2 disability (G2D) rates were obtained from the official population projections published by the National Administrative Department of Statistics of Colombia (DANE, by its Spanish acronym), which are openly accessible at: https://www.dane.gov.co/index.php/estadisticas-por-tema/demografia-y-poblacion/proyecciones-de-poblacion.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Leprosy or Hansen’s disease is one of the twenty neglected tropical diseases (NTDs) defined by the World Health Organization (WHO) [1]. Leprosy has a long history in the Americas, long before the arrival of Europeans. Some authors report the presence of ancient strains of M. lepromatosis in North and South America during the late Holocene period [2]. Leprosy is a very complex chronic communicable disease particularly because of its biological and cultural dimensions. The clinical presentation is diverse, ranging from the presence of one or more skin lesions to neuropathy (overt or silent) that is associated with deformities and disabilities, causing suffering and exclusion, particularly in poor communities [3].
The WHO defines disability as “a broad term covering any impairment, activity limitation or participation restriction affecting a person” [4]. The WHO classifies disability in leprosy patients into three grades (0, 1, and 2) in eyes, hands, and feet. Grade 0 indicates no loss of sensibility or visible deformity; grade 1 indicates loss of sensibility without visible deformity; and grade 2 indicates visible deformity [5].
Worldwide, leprosy remains a public health problem. In 2021, 140,594 new cases were reported globally, corresponding to a detection rate of 17.83 per million inhabitants [6]. This represented a 10.2% increase from 2020, when 128,405 cases were recorded. Additionally, 8,492 new cases of grade 2 disability (G2D) were reported, with a G2D rate of 1.1 per million population—this rate reflects diagnoses of patients with visible deformities [6]. The COVID-19 pandemic affected leprosy programs in most countries, early diagnosis and ongoing surveillance were disrupted due to mobility and screening restrictions. Most health services were reduced to maintaining essential services and health workers were reassigned to other services [6]. The impact on national leprosy programs was evident, as global statistics indicate.
Leprosy remains both a collective and individual problem, often overlooked worldwide, and Colombia is no exception. Obregon D in his article on the rhetoric of hygiene and science, 1920–1940, pointed out that “the advance of scientific investigation of leprosy was not supported by an encompassing project of social reform to modify the conditions of poverty, which contributed to the expansion of the disease” [7]. Despite recent publications showing “stable” indicators of the disease in Colombia [6,8], disability is still a sign of neglect in some regions of the country.
In endemic areas, continued transmission within communities, even with reduced prevalence, can result in a steady stream of new cases, some with G2D. Leprosy-associated disability may persist despite disease elimination due to delayed care-seeking and delayed diagnosis and treatment. Leprosy-associated disability in newly diagnosed cases may be related to delayed care-seeking in weakened health systems. Poverty, lack of education, social stigma, and misconceptions about disease and medical care can all contribute to delayed care-seeking [9,10]. Thus, untreated leprosy cases due to delayed diagnosis sustain community transmission of the disease [11].
G2D at diagnosis is widely recognized as an indicator of delayed case detection and of a hidden leprosy burden [11–13]. Monitoring the rate of new cases with G2D per million population provides a measure not only of program performance in early detection but also of the morbidity attributable to leprosy [12]. Persistently high G2D rates have been associated with socioeconomic vulnerability, stigma, and barriers to timely access to health services [10,14]. Despite the publication of valuable annual official reports, it is necessary to systematize and deepen the reflection on the magnitude and distribution of leprosy disability to identify municipalities that need to strengthen their prevention and control programs. In Colombia, the maximum degree of disability of each patient reported is recorded, but the anatomical location (eyes, hands, or feet) where the hypoesthesia or deformity occurs is not specified [5].
Ogunsumi DO et al. propose a standardized approach to classifying leprosy endemicity in countries and regions to improve communication and planning of control programs [15]. This research adopts this approach for Colombia, applying the metrics and method to measure and classify leprosy disability at the subnational level. The aim of this work was to characterize the spatiotemporal pattern of the most severe disability (G2D) due to leprosy and to explore the potential relationship between individual and treatment delay characteristics with degrees of disability.
Methods
Ethics statement
This study was approved by the Bioethics Committee of the National School of Public Health of Universidad de Antioquia (session 283 of March 25, 2022 – Code: 21030002-0065-2022).
Study design and data source
A cross-sectional analysis based on surveillance data was conducted from 2007 to 2020 in Colombia. The study population included all leprosy cases reported to the National Public Health Surveillance System (SIVIGILA, by its Spanish acronym), which served as the main source of information. As the entire dataset was analyzed, no sampling procedure was applied. Records with unknown department of residence, cases from abroad, and those with age less than 30 days or age equal to zero were excluded. The study followed the RECORD statement [9] (S1 Appendix), and data quality was assessed through internal consistency checks and a completeness review (S2 Appendix).
Definitions
The diagnosis of leprosy in Colombia is basically clinical [16,17], and is confirmed by smear microscopy and biopsy in order to classify the patient and define treatment and follow-up. The identification of Mycobacterium leprae or M. lepromatosis by polymerase chain reaction (PCR) is available only in research laboratories [16,18].
Colombia follows the WHO operational definitions [17,19]. A case of leprosy presents at least one of the following characteristics:
- (a). Hypopigmented skin lesions with hypoesthesia.
- (b). Impaired peripheral nerves (clear hypoesthesia, or weakness in hands and feet or face, or functional disorders such as anhidrosis).
- (c). Presence of visible deformities.
- (d). Signs of the disease with observation of bacilli in a skin smear or histopathological confirmation and who also needs treatment for leprosy.
Patients may be classified [17,19] as:
- (a). Paucibacillary leprosy: leprosy case with 1–5 skin lesions without presence of bacilli on a skin smear (Bacillary index = 0).
- (b). Multibacillary leprosy: case of leprosy with more than 5 skin lesions or nerve involvement (pure neuritis or any number of skin lesions) or presence of bacilli in a skin smear irrespective of the number of skin lesions (Bacillary index > 0).
The physical disability due to leprosy is defined in three categories [20,21]: Grade 0: no anesthesia or deformity of the eyes, hands or feet. Grade 1: decreased or absent corneal sensitivity, anesthesia in hands or feet without visible deformity. Grade 2: presence of deformities or visible eye damage (lagophthalmos and/or ectropion, trichiasis, corneal opacity), ulcers and traumatic lesions in hands or feet or mobile claw, bone resorption, foot drop and/or joint contracture.
Spatiotemporal and statistical analysis
In the analysis, the distribution of the G2D rate indicator was described through thematic maps, using the parameter categories established in the systematic review and Delphi survey conducted by Ogunsumi DO et al. [15] for G2D rates: low (< 0.5/100,000 inhabitants); medium: (0.5 to 1/100,000 inhabitants), and high (> 1/100,000 inhabitants). This analysis of G2D was performed by department and municipality of residence. The denominators of the G2D rates were the population projections 2005–2017 and 2018–2050 published by the National Administrative Department of Statistics of Colombia (DANE, by its Spanish acronym) [22].
A spatiotemporal model was constructed using the Kulldorff statistic (Poisson distribution) [23]. This technique enables early detection of outbreaks or unusual increases in cases over time and space through a prospective space-time permutation scan statistic that does not require population-at-risk data [24]. Municipalities were prioritized by locating the highest number of new cases with G2D in the most recent years between 2007 and 2020. Subsequently, the G2D rate was calculated to define the order of priority according to the highest rate identified.
Using a multinomial logistic regression model, crude (cPR) and adjusted (aPR) prevalence ratios were calculated to estimate the relationships between individual and treatment delay characteristics with disability grades 1 and 2 as dependent variables. G0D was considered as the reference category.
Data processing and analysis were performed in Power BI (Microsoft), Excel (Microsoft) and Stata version 17 (StataCorp, College Station, TX, USA). Temporal and spatial analysis of new G2D cases was conducted using SaTScan version 10.1 (M. Kulldorff, Harvard Medical School and Information Management Services Inc.) and ArcGIS Desktop version 10.8 (Esri Inc., Redlands, CA, USA).
Results
Within the 14-year period, 5240 cases of leprosy were eligible for the study out of the 5273 reported to SIVIGILA. In the analysis of the quality of the data, 48/103 variables were found to be properly filled, 55 variables had one or more empty records or omitted data and of these only one variable had errors, the total number of symptomatic cohabitants was filled in erroneously on 2 occasions, it presented a format not in accordance with the format of the leprosy form (S2 Appendix). (Fig 1).
The cases were reported mainly in men 63.8% (n = 3341), aged 15–59 years, with a median age 51 years (IQR: 35–63), residents of the municipal capital, unqualified personnel, and uninsured or in the subsidized social security health care system. (Table 1).
From the point of view of case classification, 86.4% (n = 4527) were new cases with multibacillary predominance, 47.1% (n = 2468) were identified as G0D, 18.4% (n = 966) were G1D and 9.7% (n = 507) were G2D (Table 2).
The national rate of G2D ranged between 0.03/100,000 inhabitants in 2010 and 0.05/100,000 inhabitants in 2020 (Fig 2). High rates of G2D were observed in the departments of Amazonas (years 2011, 2012 and 2018), Guaviare (2013), and Arauca (2013 and 2014). With medium ranking, the rates of G2D of the departments of Magdalena (2015), Cesar and Santander (2016), Casanare (2017), and Arauca (2019) (Fig 3).
Colombia 2007–2020.
Base layer maps of the country’s departments were obtained from open-access shapefiles provided by the National Administrative Department of Statistics of Colombia (DANE, by its Spanish acronym) through its geoportal: https://geoportal.dane.gov.co, under an open data policy. The authors confirm that the base maps can be published under the terms of the Creative Commons Attribution 4.0 International (CC BY 4.0) license: https://geoportal.dane.gov.co/acerca-del-geoportal/licencia-y-condiciones-de-uso/#gsc.tab=0. Maps were created using ArcGIS 10.8 (Esri Inc., Redlands, CA, USA).
For the G2D rate, three clusters were detected, corresponding to clusters 1, 3 and 4. Cluster 1 (RR = 6.44, p < 0.05) included 104 municipalities, located in 15 departments in the northeast of the country. Cluster 3 (RR = 7.37, p < 0.05) involved 21 municipalities from the departments of Caldas, Cundinamarca, Quindío, Risaralda, Tolima, and Valle. Cluster 4 (RR = 3.88, p < 0.05) included 24 municipalities from the departments of Cauca, Huila, Nariño, Putumayo, Tolima, and Valle (Fig 4, Table 3 and S3 Appendix).
Department and municipality boundaries were obtained from open-access shapefiles provided by the National Administrative Department of Statistics of Colombia (DANE, by its Spanish acronym) through its geoportal: https://geoportal.dane.gov.co, and are available under a Creative Commons Attribution 4.0 International (CC BY 4.0) license: https://geoportal.dane.gov.co/acerca-del-geoportal/licencia-y-condiciones-de-uso/#gsc.tab=0. The base map was created using physical and cultural vector data from Natural Earth (https://www.naturalearthdata.com), which are in the public domain and may be used without restriction: https://www.naturalearthdata.com/about/terms-of-use/. Maps were created using ArcGIS 10.8 (Esri Inc., Redlands, CA, USA).
The municipality that presented the highest rate of G2D during the study period was the municipality of Contratación in Santander (in 2016 were 194.5 cases per 100 thousand inhabitants), other six municipalities were classified as high endemic (G2D rate > 1), and three municipalities were classified as medium endemic (G2D rates between 0.5 and 1). The prioritization also included standing out in the most recent years, the municipalities of Zambrano Bolivar (2019, 16.51 per 100 thousand inhabitants), Tuluá Valle (2019, 0.93 per 100 thousand inhabitants), and Aguachica Cesar (2020, 1.69 per 100 thousand inhabitants) (Table 4).
The multinomial logistic regression model identified as risk markers for leprosy disability being 60 years or older [G1D aPR: 2.1 (95%CI: 1.0–4.5) and G2D aPR: 2.5 (95%CI 1.0–6.7)], being male [G1D aPR: 1.2 (95% CI: 1.0–1.6) and G2D aPR: 1.5 (95%CI: 1.1–2.1)] after adjusting for age group, health regimen, case type, epidemiological classification, and time from symptom onset to treatment (Table 5). Other risk factors identified were not having social security in health [G1D aPR: 1.7 (CI95%: 1.4–2.2), G2D aPR: 2.0 (CI 95%: 1.4–2.7)]; having a relapse [G1D aPR: 1.6 (CI 95%: 1.1–2.3), G2D aPR: 2.4 (CI 95%: 1.5–3.6)]; being classified as multibacillary [G1D aPR: 1.3 (CI 95%: 1.0–1.7), G2D aPR: 1.8(CI95%: 1.3–2.6)] and having time lag between onset of symptoms and treatment of 7–12 years [G1D aPR: 2.0 (CI95%: 1.1–3.5), G2D aPR: 5.7 (CI 95% 3.2–9.8)] (Table 5).
Discussion
This study analyzed the grade 2 disability in Colombia between 2007 and 2020, one of the main indicators of leprosy endemic in Colombia. This work outlined an analysis path in line with the proposal for leprosy elimination by 2030 (the WHO Global Leprosy Strategy 2021–2030: “Towards zero leprosy”), identifying the municipalities where departmental and municipal programs should (ideally) reach to guide patients and their families.
Leprosy remains a neglected disease in Colombian public health programs, despite a recorded prevalence of less than one case per 10,000 inhabitants at the national level since 1997, probably earlier [17,25]. Gussow Z, in his classic text “Leprosy, racism and public health” described in 1989 the pattern of leprosy in endemic regions that included a higher frequency of the disease in men, predominance of multibacillary (MB) forms, location of clusters of cases in the municipalities and presence of childhood leprosy [26].
This endemic pattern coincides with the data presented here in these 14 years of leprosy in Colombia. The so-called “national stability” of the endemic and the pattern described in Colombia also coincide with a study on the epidemiological behavior of leprosy conducted between 2011–2020 in several Latin American countries, showing the highest occurrence of cases in men, MB forms and G2D was more frequent in Brazil [27]. A spatiotemporal study conducted in Brazil of all new cases of leprosy with G2D at diagnosis between 2001 and 2022, detected a similar behavior to that described (97.4% aged > 14 years, 70.2% male, 87.6% with low educational level and 90.2% multibacillary) [28].
This pattern of predominance of MB forms has implications for the follow-up of patients, their contacts, and epidemiological surveillance (i.e., the classification of patients and integrity of the information system). The specialized international literature indicates that reactional phenomena in leprosy are associated with neural damage and potential disability in more than 60% of patients with MB leprosy during the first 6 months of treatment [29]. The Colombian leprosy protocol considered as the basic orientation for rural physicians, lacks guidelines for the preventive and therapeutic management of reactional phenomena. The data presented in this study warns about this aspect due to the national frequency of multibacillary forms (65.9%) and the statistical relationship found between the degrees of disability (outcome) and this classification of the disease (exposure).
The appearance of disabilities reiterates that there are some gaps in the control of the disease. Indeed, the national predominance of multibacillary forms may indicate the occurrence of active transmission of the disease, as stated by Santana EMF [30]. Situations like this reflect contexts where transmission is intensified by the low detection of new cases and the delayed diagnosis and treatment, which increases disability, as shown by the national, departmental, and municipal leprosy rates.
These findings are consistent with a systematic review conducted between 2000 and 2021 from original studies of Asia (China, India, Nepal, Bangladesh, Myanmar), South America (Brazil, Colombia, Peru, Paraguay) and the United Kingdom, Authors identified healthcare factors related to delays in case detection in leprosy, including misdiagnosis as a central factor in delayed care, high number of pre-diagnosis consultations, lack of referral centers, healthcare personnel, and case detection methods. Geographic, financial, and organizational barriers were also identified. The authors recommended ensuring the sustainability of national leprosy control programs, including staff training within integrated health services [10].
In this sense, Jacobson RR stated that bacteriological healing cannot reverse established neural damage [31]. He provided guidance on the need for specialized medical care of reactional phenomena in an environment where experience and knowledge about leprosy are reduced. In 2013, Sales AM et al. in a study conducted in Brazil, concluded that patients with neural damage had a greater than 65% risk of worsening disability and that prompt treatment of reactional episodes allows prevention of disabilities [32].
Like other low-endemic countries, Colombia presents patterns of leprosy occurrence clustered at the subnational level (departmental or municipal). The spatial-temporal analysis of the indicator identified 149 municipalities and 3 clusters of G2D, particularly in the northeastern part of the country, as the area that has suffered the most from the disease [33], this departmental distribution has interesting historical particularities. It coincides, with some understandable variations due to the passage of time (and it is possible to see it in the maps), with what was published by Montoya and Flórez JB in 1906 and reproduced by Cardona H in 2011 [34], by Camargo D and Orozco LC in 1996 [35], by Cardona-Castro N in 2018 [36], and by the research presented here.
This study has some limitations. Systematizing and interpreting information on this disease in Colombia is difficult due to the heterogeneity in the quality of epidemiological surveillance information across departments and municipalities. These limitations include underreporting of cases, variations in diagnostic capacity across regions, and incomplete clinical records that may alter the accuracy of estimates of disease frequency and disability due to leprosy. Furthermore, it must be recognized that the model used may not be sensitive to detecting irregularly shaped clusters, in addition to its computational complexity [37]. However, this effort is valuable within the public health context for the discussion and methodological orientation of current proposals for leprosy elimination in Colombia.
Conclusions
Disability due to leprosy in Colombia is heterogeneous, with annual variations in its departments and municipalities. The prevention of leprosy-related disabilities is a historical national debt. The lack of information on the disease is one of the symptoms of its invisibility and a neglect of historical nuances on which a good program and a clear epidemiological surveillance strategy can be reconstructed.
National indicators hide departmental and particularly municipal variations. It is recommended that the necessary actions be taken to promote the strategy of active epidemiological surveillance in the prioritized municipalities (particularly in contacts of MB forms) to define the individual follow-up of patients with G1D–G2D and the epidemiological field study of new cases. Additionally, it is important to distinguish disability in eyes, hands, and feet to guide the necessary measures to prevent the progression of disability, including early treatment and referral to specialized centers when necessary.
Supporting information
S3 Appendix. G2D cases in the departments and municipalities included in the clusters.
https://doi.org/10.1371/journal.pntd.0013514.s003
(XLSX)
References
- 1.
World Health Organization. Defining criteria to declare elimination of leprosy. World Health Organization. 2020. https://www.who.int/publications/i/item/9789290228332
- 2. Lopopolo M, Avanzi C, Duchene S, Luisi P, de Flamingh A, Ponce-Soto GY, et al. Pre-European contact leprosy in the Americas and its current persistence. Science. 2025;389(6758):eadu7144. pmid:40440428
- 3. Faizal M, Rincón G, Betancourth M, Agudelo C, Pardo R, Gaitán H, et al. Guía de atención de lepra. 2011;17:359–88. http://www.med-informatica.net/TERAPEUTICA-STAR/Lepra_GuiaMPSindependiente_guias18.pdf
- 4.
World Health Organization. Interruption of transmission and elimination of leprosy disease. 2023. https://www.who.int/publications/i/item/9789290210467
- 5.
Grupo de Vigilancia y Control de enfermedades transmisibles INS Colombia. Protocolo de vigilancia de lepra código 450. Instituto Nacional de Salud. 2022. https://www.ins.gov.co/buscador-eventos/Paginas/Fichas-y-Protocolos.aspx
- 6. Global T, Strategy L. Weekly epidemiological record Relevé épidémiologique hebdomadaire. Wkly Epidemiol Rec. 2022;97:429–52.
- 7. Obregón D. The anti-leprosy campaign in Colombia: the rhetoric of hygiene and science, 1920-1940. Hist Cienc Saude Manguinhos. 2003;10(Suppl 1):179–207. pmid:14650413
- 8.
Pérez Clavijo CL. Informe de evento lepra o enfermedad de Hansen. Bogotá Colombia: Instituto Nacional de Salud. 2021. https://www.minsalud.gov.co/salud/publica/PET/Paginas/lepra.aspx
- 9. Dharmawan Y, Fuady A, Korfage I, Richardus JH. Individual and community factors determining delayed leprosy case detection: A systematic review. PLoS Negl Trop Dis. 2021;15(8):e0009651. pmid:34383768
- 10. Dharmawan Y, Fuady A, Korfage IJ, Richardus JH. Delayed detection of leprosy cases: A systematic review of healthcare-related factors. PLoS Negl Trop Dis. 2022;16(9):e0010756. pmid:36067195
- 11. Quilter EEV, Butlin CR. Is the WHO ‘global’ rate indicator an accurate reflection of the annual leprosy-associated disability burden experienced worldwide?. LEPROSY. 2024;95(2).
- 12.
World Health Organization. WHO expert committee on leprosy. World Health Organization. 2012. https://iris.who.int/handle/10665/75151
- 13.
World Health Organization. Towards zero leprosy: global leprosy (Hansen’s disease) strategy 2021–2030. South-East Asia: World Health Organization. 2021. https://iris.who.int/handle/10665/340774
- 14. Raposo MT, Reis MC, Caminha AV de Q, Heukelbach J, Parker LA, Pastor-Valero M, et al. Grade 2 disabilities in leprosy patients from Brazil: Need for follow-up after completion of multidrug therapy. PLoS Negl Trop Dis. 2018;12(7):e0006645. pmid:30011288
- 15. Ogunsumi DO, Lal V, Puchner KP, van Brakel W, Schwienhorst-Stich E-M, Kasang C, et al. Measuring endemicity and burden of leprosy across countries and regions: A systematic review and Delphi survey. PLoS Negl Trop Dis. 2021;15(9):e0009769. pmid:34543282
- 16.
Instituto Nacional de Salud de Colombia. Guía para la vigilancia por laboratorio de Mycobacterium leprae. Bogotá: Dirección Redes en Salud Pública. 2017. https://www.ins.gov.co/buscador/Informacindelaboratorio/GuiaparalavigilanciaporlaboratoriodeMycobacteriumleprae.pdf
- 17.
Ministerio de Salud y Protección Social de Colombia. Plan Estratégico Nacional de Prevención y Control de la Enfermedad de Hansen. 2015. https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/PP/ET/Plan-strategico-enfermedad-hansen-2016-2025.pdf
- 18. Cardona-Castro N, Escobar-Builes MV, Serrano-Coll H, Adams LB, Lahiri R. Mycobacterium lepromatosis as Cause of Leprosy, Colombia. Emerg Infect Dis. 2022;28(5):1067–8. pmid:35450566
- 19.
Asia World Health Organization. Guidelines for the diagnosis, treatment and prevention of leprosy. New Delhi: World Health Organization. 2018. https://iris.who.int/handle/10665/274127
- 20. Rathod SP, Jagati A, Chowdhary P. Disabilities in leprosy: an open, retrospective analyses of institutional records. An Bras Dermatol. 2020;95(1):52–6. pmid:31952993
- 21. Guerrero Guerrero MI. La lepra: una enfermedad vigente. Med. 2020;42(1):109–11.
- 22.
National Administrative Department of Statistics (DANE). Projections and back-projections of the national population for the period 1950-2017 and 2018-2070 based on the National Population and Housing Census 2018. 2020. https://www.dane.gov.co/index.php/estadisticas-por-tema/demografia-y-poblacion/proyecciones-de-poblacion
- 23. Kulldorff M. A spatial scan statistic. Communications in Statistics - Theory and Methods. 1997;26(6):1481–96.
- 24. Kulldorff M, Heffernan R, Hartman J, Assunção R, Mostashari F. A space-time permutation scan statistic for disease outbreak detection. PLoS Med. 2005;2(3):e59. pmid:15719066
- 25.
Casas ES. Los mutilados del oprobio: estudio sobre la lepra en una región endémica de Colombia. Colcultura. 1995.
- 26. Gussow Z. Leprosy, Racism, and Public Health. Routledge. 2021.
- 27. Cáceres-Durán MÁ. Epidemiological behavior of leprosy in several Latin American countries, 2011-2020Comportamento epidemiológico da hanseníase em vários países da América Latina, 2011-2020. Rev Panam Salud Publica. 2022;46:e14. pmid:35350456
- 28. Matos TS, de Souza CDF, de Oliveira Fernandes TRM, Santos MB, de Brito RJVC, Matos DUS, et al. Time trend and identification of risk areas for physical disability due to leprosy in Brazil: An ecological study, 2001-2022. BMC Infect Dis. 2025;25(1):320. pmid:40050792
- 29. Lockwood DNJ, Lambert S, Srikantam A, Darlong J, Pai VV, Butlin CR, et al. Three drugs are unnecessary for treating paucibacillary leprosy-A critique of the WHO guidelines. PLoS Negl Trop Dis. 2019;13(10):e0007671. pmid:31671087
- 30. de Santana EMF, de Brito KKG, Antas EMV, Nogueira J de A, Leadebal ODCP, da Silva MA, et al. Factors associated with the development of physical disabilities in Hansen’s disease. Rev Inst Med Trop Sao Paulo. 2018;60:e27. pmid:29972464
- 31. Jacobson RR, Krahenbuhl JL. Leprosy. Lancet. 1999;353(9153):655–60. pmid:10030346
- 32. Sales AM, Campos DP, Hacker MA, da Costa Nery JA, Düppre NC, Rangel E, et al. Progression of leprosy disability after discharge: is multidrug therapy enough?. Trop Med Int Health. 2013;18(9):1145–53. pmid:23937704
- 33. Gómez L, Rivera A, Vidal Y, Bilbao J, Kasang C, Parisi S, et al. Factors associated with the delay of diagnosis of leprosy in north-eastern Colombia: a quantitative analysis. Trop Med Int Health. 2018;23(2):193–8. pmid:29230912
- 34. Rodas HC, Valencia MFV. Disfiguring disease, degeneration and climate in Colombia, 1880-1920. Hist Cienc Saude Manguinhos. 2011;18(2):303–20. pmid:21779688
- 35.
Orozco Vargas LC, Rodriguez Toro G, Hernandez CA. Lepra. Bogotá: Instituto Nacional de Salud. 1996.
- 36. Cardona-Castro N. Leprosy in Colombia. Curr Trop Med Rep. 2018;5(2):85–90.
- 37. Więckowska B, Górna I, Trojanowski M, Pruciak A, Stawińska-Witoszyńska B. Searching for space-time clusters: The CutL method compared to Kulldorff’s scan statistic. Geospat Health. 2019;14(2):10.4081/gh.2019.791. pmid:31724381