title: Factors Contributing to the Delay in Diagnosis and Continued Transmission of Leprosy in Brazil--An Explorative, Quantitative, Questionnaire Based Study.
abstract: BACKGROUND
  Leprosy is a leading cause of preventable disability worldwide. Delay in diagnosis of patients augments the transmission of infection, and allows progression of disease and more severe disability. Delays in diagnosis greater than ten years have been reported in Brazil. To reduce this delay, it is important to identify factors that hinder patients from presenting to doctors, and those that delay doctors from diagnosing patients once they have presented. This study aimed to explore factors associated with the delayed diagnosis of leprosy in Brazil.
  
  
  RESULTS
  This is an exploratory study using a self-constructed questionnaire delivered to patients attending three leprosy referral clinics across three states in Brazil. Data were analysed to determine associations between variables and the time taken for participants to present to the health-service, and between variables and the time taken for doctors to diagnose participants once they had presented. Participants who suspected they had leprosy but feared community isolation were 10 times more likely to wait longer before consulting a doctor for their symptoms (OR 10.37, 95% CI 2.18-49.45, p = 0.003). Participants who thought their symptoms were not serious had a threefold greater chance of waiting longer before consulting than those who did (OR 3.114, 95% CI 1.235-7.856, p = 0.016). Forty-two point six per cent of participants reported initially receiving a diagnosis besides leprosy. These had a three times greater chance of receiving a later diagnosis of leprosy compared to those not misdiagnosed or not given a diagnosis (OR 2.867, 95% CI 1.288-6.384, p = 0.010).
  
  
  CONCLUSIONS
  This study implies a need for patient education regarding leprosy symptoms and the reduction of stigma to encourage patients to present. The high rate of misdiagnosis reported suggests a need to increase clinician suspicion of leprosy. Further education regarding disease symptoms in medical school curriculums may be advisable.
authors.affiliation: Population Science and Humanities, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Mary
authors.initials: M
authors.lastname: Henry
authors.affiliation: Instituto Lauro de Souza Lima, Bauru, São Paulo, Brazil.
authors.forename: Noêmi
authors.initials: N
authors.lastname: GalAn
authors.affiliation: Population Science and Humanities, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Katherine
authors.initials: K
authors.lastname: Teasdale
authors.affiliation: Instituto Lauro de Souza Lima, Bauru, São Paulo, Brazil.
authors.forename: Renata
authors.initials: R
authors.lastname: Prado
authors.affiliation: Population Science and Humanities, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Harpreet
authors.initials: H
authors.lastname: Amar
authors.affiliation: Faculdade de Medicina de Marilia (FAMEMA), Marilia, São Paulo, Brazil.
authors.forename: Marina S
authors.initials: MS
authors.lastname: Rays
authors.affiliation: Population Science and Humanities, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Lesley
authors.initials: L
authors.lastname: Roberts
authors.affiliation: Centro Referencia em Tuberculose e Hanseniase, Sinop, Mato Grosso, Brazil.
authors.forename: Pedro
authors.initials: P
authors.lastname: Siqueira
authors.affiliation: Population Science and Humanities, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Gilles
authors.initials: G
authors.lastname: de Wildt
authors.affiliation: Instituto Lauro de Souza Lima, Bauru, São Paulo, Brazil.
authors.forename: Marcos
authors.initials: M
authors.lastname: Virmond
authors.affiliation: Department of Clinical Immunology, School of Infection and Immunity, University of Birmingham, Birmingham, United Kingdom.
authors.forename: Pranab K
authors.initials: PK
authors.lastname: Das
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001938:Brazil / Q000453:epidemiology; D057210:Delayed Diagnosis; D003951:Diagnostic Errors; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007918:Leprosy / Q000175:diagnosis* / Q000453:epidemiology* / Q000635:transmission; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D012307:Risk Factors; D057545:Social Stigma; D011795:Surveys and Questionnaires; D055815:Young Adult