management of leprosy in detail

1. LEPROSY MANAGEMENT

5. No of new cases diagnose >1000 (2015)
127326
26395
17202
4237 3976 3970 2892
27512571 2256 1977 1617 1487 1335
0
20000
40000
60000
80000
100000
120000
140000

6. Priority countries at global level
Based on absolute and relative
burden
Composite index:
◦ Prevalence
◦ Annual new case detection
◦ Annual new case detection rate
◦ proportion of children
◦ Proportion of G2D among new
cases
◦ G2D rate per million

7. District wise Case load(2072/73) National average 90.00
White (districts) n=7 9.4%
Green (districts) n=50 66.60%
Red (districts) n=18 24.00%
Highest PR Dhanusa=3.25
National Target (2016-20)
•Elimination in District level by 2018
(by the end of 2015, 57 districts have
achieved elimination status)

8. Leprosy Control
1. To interrupt the transmission of infection
2. To treat patients in order to achieve cure and where
ever possible complete rehabilitation
3. To prevent development of associated deformities

9. Principles of Action:
Focus on early case detection before visible deformity occur.
(Special focus on children)
Target detection among higher risk groups through conducting
campaigns
Develop national plans to ensure screening of all close contacts.
Promote steps to move towards the use of shorter uniform MDT
Incorporate specific interventions against stigma and
discrimination due to leprosy

10. Management
Five main principles of treatment:
1. Stop the infection with chemotherapy.
2. Treat reactions and reduce the risk of nerve damage.
3. Educate the patient to cope with existing nerve damage, in particular
anaesthesia.
4. Treat the complications of nerve damage.
5. Rehabilitate the patient socially and psychologically.

11. Vision, Mission, Goal 2016 - 2020
• To make leprosy free Nepal (no new
leprosy cases and all the needs of existing
leprosy affected persons having been fully
met)
Vision
• To provide: accessible and acceptable cost
effective quality leprosy services including
rehabilitation and continue to provide such
services as long as and wherever needed
Mission
• To further reduce disease burden due to
leprosy and end its consequences including
disability and stigma.
Goal

12. Objectives
Achieve elimination status in all
districts by 2020
Provide quality leprosy services through
integrated health services
Reduce transmission of leprosy through
diverse approaches
Achieve the surveillance
performance indicator targets

13. Strategic pillars:
Pillar 1: Stop transmission of leprosy & its complications
Pillar 2: Stop discrimination against leprosy and promote
inclusion
Pillar 3: Strengthen enablers: government ownership,
coordination, partnership and capacity building

16. Management
Multidrug Chemotherapy
Main objectives
To interrupt the transmission of infection
To ensure early detection and treatment of cases to prevent deformities
To prevent drug resistance

18. Pauci or Multi Bacillary
BI (bacterilogical index/ not bacillary) in slit-skin smears
 if BI is not available, the number of skin lesions

19. Definitions
Regular Treatment
If he or she has received MDT for at least 2/3rd of months in any interval of time
Defaulter case
Patient on MDT , who has not collected treatment for 12 consecutive months
Relapsed Case
Patient whose therapy has terminated, having successfully completed adequate
drug therapy but subsequently develop signs and symptoms of leprosy

20. Defaulter Case
Defaulter who returns to the health center for treatment and shows one or more
of the following signs should be given a new course of MDT:
Reddish and/or elevated skin lesions appearance of new skin
lesions since last examination
new nerve involvement since last examination
Lepromatous nodules
Signs of erythema nodosum leprosum (ENL) or reversal reaction

21. Management
WHO recommended regimen for adults:
Pauci-bacillary Multi-bacillary
Definition 5 or < lesions > 5 lesions
Duration of therapy 6 months (can be
completed in 9 months)
12 months (can be
completed in 18 months)
Drugs Rifampicin, 600mg
Supervised (monthly)
Dapsone, 100mg
Not Supervised (daily)
Rifampicin, 600mg and
Clofazimine, 300mg
Dapsone, 100mg and
Clofazimine, 50mg

22. Adult PB pack
Adult MB pack

23. Child PB Pack
Child MB Pack

24. Duration of Treatment
& Benefits of BPs
MB Leprosy:
MB Blister packs for 12 months within 18 months
Low BI: 12 months
High BI (> 4+) : 18 months
PB Leprosy:
PB Blister packs for 6 months within 9 months

25. Management
Unable or refusal to take Rifampicin
PB Leprosy:
6 months regimen consisting of daily administration of following;
50 mg Clofazimine with 2 of the following drugs:
400 mg ofloxacin, 100 mg Minocycline
OR
500mg Clarithromycin

26. Management
Unable or refusal to take Rifampicin
MB Leprosy
Above regimen followed by daily administration of 50 mg Clofazimine with
100 mg Minocycline OR 400mg Ofloxacin

27. Management
Unable or refusal to take Clofazimine
Replaced by Ofloxacin 400 mg daily OR Minocycline 100 mg daily
Unable or refusal to take Dapsone
PB Leprosy
Clofazimine 50 mg daily substituted for dapsone
MB Leprosy
No further medication required

28. Dapsone (DDS)
Diamino diphenyl sulfone
MoA:
Inhibition of PABA incorporation into
folic acid inhibit folic acid synthesis
Adverse Effects:
◦ Mild haemolytic anaemia
◦ Dose related toxicity
◦ G6PD deficiency more susceptible
◦ Dose > 50 mg/day produce
haemolysis
◦ Gastric intolerance: Nausea,
anorexia (in beginners)
◦ Cutaneous reaction: Allergic rashes,
fixed drug eruption,
hypermelanosis, photoxicity
◦ Hepatitis

29. Rifampicin
Potent bactericidal for M. leprae
MoA:
Inhibits DNA dependent RNA polymerase synthesis
Adverse Effect
Hepatotoxicity
Flu like syndromes
Red color urine (Adequate counselling)

30. Clofazimine
Phenazine derivative
Leprostatic and anti inflammatory properties
MoA
Interfere with template function of DNA in M. leprae
Disruption of mitochondrial electron transport chain

31. Clofazimine
ADRs:
Skin
◦ Reddish-black discoloration of skin
◦ Discoloration of hair, body secretion
◦ Dryness of skin and itching
◦ Acneform eruption
◦ Conjunctival pigmentation (cosmetic concern)
GI symptom:
◦ Enteritis with intermittent loose stools, nausea, abdominal pain, anorexia
and weight loss (when higher doses used to control lepra reaction)

32. Second Line Drugs
Ethionamide
Alternative to clofazimine
Inhibition of mycolic acid synthesis
ADRs: Anorexia, Nausea, Epigastric discomfort
Moxifloxacin
Bactericidal
Alternative to rifampicin

33. Second Line Drugs
Minocycline
Highly lipophilic
Relief of lepromatous symptoms
ADRs: Vertigo, Grey pigmentation of skin lesion
Clarithromycin
Alternative to MDT regimen

34. Patient Education
After 3 days of chemotherapy, they are not infectious and can lead a normal
social life
Gross deformities are not inevitable
Anaesthetic hands or feet special care to avoid and treat burns and other
minor injuries
Good footwear

40. Reconstructive surgeries:

41. Treatment of Other Complications

42. Leprosy Vaccines
Several candidate vaccines have been investigated:
BCG
BCG + killed M. leprae.
Killed M. leprae
Indication
Immunoprophylaxsis
Immunochemotherapy: Highly bacillated patients

43. Rehabilitation
Physical and mental restoration
Social, psychological and vocational rehabilitation
Community based rehabilitation strategy
Equlization of oppurtunities
Intersectoral Co-ordination

45. Concern for social stigmas in leprosy

46. Dealing with Stigmas!
achieving the acceptance of the leprosy patients in the
community along with social status culturally acceptable in
the absence of disease/ill health
Spreading awareness
Developing understandings & concepts based on scientific
knowledge
Preventing iatrogenic stigma
Involving communities/societies (CBRs)

47. References:
1. WHO Guidelines for Diagnosis, Prevention & Treatment of Leprosy, 2018
2. Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases,
Neena Khanna, 5th Edition
3. Clinical Dermatology – Virendra Sehgal
4. Uptodate.com