Leprosy by dr. alteiob yousif


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Leprosy by dr. alteiob yousif

  1. 1. UNIVERSITY OF MEDICAL SCIENCESAND TECHNOLOGYLEPROSY(Hansens disease)Presented by;Dr.AlteibYousifDec 201212/16/20129:55 AMDr. Alteib
  2. 2. CONTENT History and background Key facts Types of leprosy Risk factors Signs and symptoms Complications Diagnosis Treatment and prevention Global current situation Situation in Sudan Elimination of leprosy12/16/20129:55 AMDr. Alteib
  3. 3. HISTORY & BACKGROUND Leprosy was recognizedin the ancient civilizations ofChina, Egypt and India. The earliest documentedaccount of leprosy is around 1550B.C on Egyptian papyrus. Throughout history, the badlyaffected have often been hatedby their communities and families (stigmatization).12/16/20129:55 AMDr. Alteib
  4. 4. Con.. Although leprosy wastreated differently in thepast, the first advance intreatment occurred in the1940s with developmentof the drug Dapsone,which arrested the disease.But duration of the treatmentwas many years, even a lifetime, making it difficult forpatients to follow.12/16/20129:55 AMDr. Alteib
  5. 5. Con.. In the 1960s, M. leprae started todevelop resistance to Dapsone, theworld’s only known anti-leprosy drugat that time. In the early 1960s, Rifampicin andClofazimine, the other twocomponents of recommendedmultidrug therapy (MDT), werediscovered.12/16/20129:55 AMDr. Alteib
  6. 6. Con.. In 1981,WHO Study Grouprecommended MDT. Since 1995,WHO provides free MDT forall patients in the world, initially throughthe drug fund provided by the NipponFoundation and since 2000, through theMDT donation provided by Novartis andthe Novartis Foundation for SustainableDevelopment.12/16/20129:55 AMDr. Alteib
  7. 7. KEY FACTS Leprosy is a chronic infectious disease causedby an acid-fast, rod-shapedbacillus, Mycobacterium leprae. Official figures show that almost 182 000people, mainly in Asia and Africa, wereaffected at the beginning of 2012, withapproximately 219 000 new cases reportedduring 2011.12/16/20129:55 AMDr. Alteib
  8. 8. Con.. M. leprae multiplies very slowly and theincubation period of the disease is about fiveyears. Symptoms can take as long as 20 years toappear. Leprosy is not highly infectious. Leprosy is transmitted via droplets, from thenose and mouth, during close and frequentcontacts with untreated cases.12/16/20129:55 AMDr. Alteib
  9. 9. Con.. Untreated, leprosy can cause progressive andpermanent damage to the skin, nerves, limbsand eyes. The disease mainly affects the skin, theperipheral nerves, mucosa of the upperrespiratory tract and also the eyes. Leprosy is curable and treatment provided inthe early stages averts disability.12/16/20129:55 AMDr. Alteib
  10. 10. RISK FACTORS FOR LEPROSY People who live in the areas where leprosy isendemic (parts of India, China, Japan, Nepal,Egypt, and other areas) and especially thosepeople in constant physical contact with infectedpeople. There is some evidence that genetic defects inthe immune system may cause certain people tobe more likely to become infected (region q25 onchromosome 6). People who handle certain animals that areknown to carry the bacteria (armadillos,chimpanzee,…) are at risk of getting the bacteriafrom the animals12/16/20129:55 AMDr. Alteib
  11. 11. CLASSIFICATION OF LEPROSYTwo types of classifications: Skin smear result classification Clinical classification12/16/20129:55 AMDr. Alteib
  12. 12. Con..SKIN SMEAR RESULTS CLASSIFICATION1. Paucibacillary leprosy (PB) – few Bacilli;Two to five skin lesions with negative skinsmear results at all sites2. Multibacillary leprosy (MB);Any form of leprosy in which the patient showspositive smears at any site12/16/20129:55 AMDr. Alteib
  13. 13. Con..CLINICALCLASSIFICATION1. Indeterminate leprosy (IL)2.Tuberculoid leprosy (TT)3. Lepromatous leprosy (LL)4. Borderline leprosy (BL):Borderline tuberculoid leprosy (BT)Borderline borderline leprosy (BB)Borderline lepromatous leprosy (BL)12/16/20129:55 AMDr. Alteib
  14. 14. Con..Adapted from Ramos-e-Silva M , Castro MCR. Mycobacterial infections.In: Bolognia JL; Jorizzo JL; Rapini RP. Dermatology. 2nd edition. London: Mosby, 2008; 1109.12/16/20129:55 AMDr. AlteibCLASSIFICATION OF LEPROSYClinical findings Lepromatous Leprosy Borderline Leprosy Tuberculoid leprosy IndeterminateleprosyType of lesions Macules, papules, nodules,diffuse infiltrationMacules, papules,plaques, infiltrationInfiltrated plaques,oftenhypopigmentedMacules,oftenhypopigmentedNumber Numerous Many One or few (up to 5)lesionsOne or fewDistribution Symmetric Tendency to symmetry Localized,asymmetricVariableDefinition Vague, difficult to distinguishnormal versus affected skinLess well- definedbordersWell-defined, sharpbordersNot always definedSensation Not affected Diminished Absent ImpairedBacilli in skinlesionsMany (globi) Many None detected Usually nonedetectedAdapted from Ramos-e-Silva M , Castro MCR. Mycobacterial infections.In: Bolognia JL; Jorizzo JL; Rapini RP. Dermatology. 2nd edition. London: Mosby, 2008; 1109.
  15. 15. SIGNS AND SYMPTOMSTuberculoid leprosy:Early signs and symptomsof Tuberculoid leprosy caninclude one or more slightred patches of skin thatappear on the trunk orextremities.12/16/20129:55 AMDr. Alteib
  16. 16. Con..Other signs and symptoms ofTuberculoid leprosy include:• Skin stiffness and dryness• Loss of fingers and toes• Eye problems, which leadsto blindness• Severe pain• Muscle weakness, especiallyin the hands and feet• Enlarged nerves, especially• those around the elbow and knee.12/16/20129:55 AMDr. Alteib
  17. 17. Loss of eyebrows and eyelashes12/16/20129:55 AMDr. Alteib
  18. 18. 12/16/20129:55 AMDr. AlteibHypopigmented MaculeinTuberculoid LeprosyNose Deformity BorderlineTuberculoidLeprosy Skin Lesion
  19. 19. Con.. It is important to note that not all people withleprosy lose their fingers and toes. With earlydiagnosis and treatment, many of these signsand symptoms of leprosy can be prevented. Many patients with Tuberculoid disease caneven self-heal without benefit of treatment. In order to prevent problems with fingers ortoes, people should avoid injury and infectionsto these areas and take their medicines asprescribed.12/16/20129:55 AMDr. Alteib
  20. 20. Con..Lepromatous leprosy:It is the severe form ofleprosy, signs andsymptoms can Includea symmetrical skin rashMore commonly found on: Elbows Knees Buttocks Face Ears Wrists.12/16/20129:55 AMDr. Alteib
  21. 21. arm nodules in lepromatous leprosy12/16/20129:55 AMDr. Alteib
  22. 22. Con..Other signs and symptomsof Lepromatous leprosy:• Thinning of eyebrowsand eyelashes• Thickened skin on face• Nasal stuffiness• Bloody nose• Laryngitis• Collapsing of the nose12/16/20129:55 AMDr. Alteib
  23. 23. Con..• Swelling of the lymph nodes in thegroin and armpits• Scarring of the testes that leads toinfertility• Enlargement of male breasts.12/16/20129:55 AMDr. Alteib
  24. 24. ASSOCIATED COMPLICATIONS Leprosy is probablythe most common causeof crippling in the handsworldwide. Leprosy complicationscan include:BlindnessLoss of fingers or toesfollowing an injury or infection12/16/20129:55 AMDr. Alteib
  25. 25. DIAGNOSIS Diagnosis of leprosy is mostcommonly based on the clinical signsand symptoms. These are easy toobserve by any health worker after ashort period of training. Only in rare instances there is a needto use laboratory and otherinvestigations to confirm a diagnosisof leprosy.12/16/20129:55 AMDr. Alteib
  26. 26. Con.. In an endemic country or area, anindividual should be regarded ashaving leprosy if he or she showsONE of the following cardinal signs: skin lesion consistent with leprosyand with definite sensory loss, withor without thickened nerves positive skin smears12/16/20129:55 AMDr. Alteib
  27. 27. TREATMENTMultidrug therapy (MDT)treatment has been madeavailable byWHO free ofcharge to all patientsworldwide since 1995,and provides a simpleyet highly effective curefor all types of leprosy.12/16/20129:55 AMDr. Alteib
  28. 28. Con.. The drugs used inWHO-MDT are acombination of: Among these Rifampicin is the mostimportant anti leprosy drug and therefore isincluded in the treatment of both types ofleprosy.12/16/20129:55 AMDr. AlteibMulti Bacillary (MB) leprosy Paucibacillary (PB)leprosyRifampicin + Clofazimine + Dapsone Rifampicin + Dapsone
  29. 29. WHO recommended MDT regimens12/16/20129:55 AMDr. AlteibMultibacillary (MB) Paucibacillary (PB) Single Skin Lesion (PB)Adults:Rifampicin: 600 mg/mDapsone: 100 mg/dClofazimine:300mg/m+50mg/dAdults:Rifampicin: 600mg/mDapsone: 100mg/dAdults:Rifampicin: 600 mgOfloxacin: 400 mgMinocycline:100mgChildren 10-14 years:Rifampicin: 450mg/mDapsone: 50 mg/dClofazimine: 150mg/m & 50mg/dChildren 10-14 years:Rifampicin: 450mg/mDapsone: 50mg/dChildren 10-14 years:Rifampicin: 300 mgOfloxacin: 200 mgMinocycline: 50 mgChildren less than 10:Rifampicin: 300mg/mDapsone: 25 mg/dClofazimine: 100 mg/m & 50mgtwice/wChildren less than 10:Rifampicin: 300mg/mDapsone: 25 mg/dChildren less than 10:Not recommended forpregnant womenand children < 5 yrsDuration= 12 months Duration= six months Duration= once
  30. 30. Con..12/16/20129:55 AMDr. Alteib
  31. 31. Con.. Treatment of leprosy with only one anti leprosydrug will always result in development of drugresistance to that drug. Treatment with Dapsone or any other antileprosy drug used as mono therapy should beconsidered as unethical practice.12/16/20129:55 AMDr. Alteib
  32. 32. Con.. The role for surgery in the treatment of leprosyoccurs after medical treatment (antibiotics) hasbeen completed with negative skin smears (nodetectable acid-fast bacilli) and is often onlyneeded in advanced cases. Surgery is individualized for each patient withthe goal to attempt cosmetic improvementsand, if possible, to restore limb function andsome neural functions that were lost to thedisease.12/16/20129:55 AMDr. Alteib
  33. 33. PREVENTION Prevention of contact with droplets fromnasal and other secretions from patients withuntreated M. leprae infection. Treatment of patients with appropriateantibiotics stops the person from spreadingthe disease. People who live with individuals who haveuntreated leprosy are about eight times aslikely to develop the disease, because theyhave close proximity to infectious droplets.12/16/20129:55 AMDr. Alteib
  34. 34. Con.. Leprosy is not hereditary, but recent findingssuggest susceptibility to the disease mayhave a genetic basis. There is no commercially available vaccineavailable to prevent leprosy. However, thereare reports of using BCG vaccine, the BCGvaccine along with heat-killed M. lepraeorganisms.12/16/20129:55 AMDr. Alteib
  35. 35. PROGNOSIS The prognosis of leprosy varies with the stage ofthe disease when first diagnosed and treated. Early diagnosis and treatment limits or preventstissue damage so the person has a goodoutcome. However, if the patients disease has progressedto more advanced disease, the complications canmarkedly affect the patients lifestyle, and thusthe condition has a fair to poor prognosis.12/16/20129:55 AMDr. Alteib
  36. 36. GLOBAL CURRENT SITUATION Leprosy control has improved significantlydue to national and sub-national campaignsin most endemic countries. Integration of primary leprosy services intoexisting general health services has madediagnosis and treatment of the disease easy.12/16/20129:55 AMDr. Alteib
  37. 37. Con.. The implementation of the global leprosystrategy 2011–2015 national leprosyprograms now focus more on underservedpopulations and inaccessible areas toimprove access and coverage. Since control strategies are limited, nationalprograms actively improve case holding,contact tracing, monitoring, referrals andrecord management.12/16/20129:55 AMDr. Alteib
  38. 38. Con.. According to official reports received from105 countries and territories, the globalregistered prevalence of leprosy at thebeginning of 2012 stood at 181 941 cases. The number of cases detected during 2011was 219 075 compared with 228 474 in 2010.12/16/20129:55 AMDr. Alteib
  39. 39. Con.. Pockets of high endemicity still remain insome areas of Brazil, Indonesia, Philippines,Democratic Republic of Congo, India,Madagascar, Mozambique, Nepal, and theUnited Republic ofTanzania. All endemic countries remain highlycommitted to eliminating the disease, andcontinue to intensify their leprosy controlactivities.12/16/20129:55 AMDr. Alteib
  40. 40. SITUATION IN SUDAN In 2002 theWHO launched a leprosy controlprogram, with rapid simple diagnostic toolsand the delivery of multi-drug therapy (MDT). All efforts are constrained by instability, lackof suitable logistics, climate difficulties andpoor roads, lack of resources and changes inhealth personnel.12/16/20129:55 AMDr. Alteib
  41. 41. Con.. SITUATION IN SUDAN In Northern Sudan 725 cases of leprosy weredetected in 2008, 553 of which were multibacillary (MB). The cure rate for Multi Bacillary cases was69.5%. However, in the Kordofan and Darfurstates the Multi Bacillary cure rate was 57.3%due to instability, population movement andgreat stigma. In Khartoum the Multi Bacillary cure rate is80.7%, which percentage is affected bydefaulters, re-registered patients and stigma.12/16/20129:55 AMDr. Alteib
  42. 42. Con.. SITUATION IN SUDANNumber of new cases in Sudan detectedannually since 200412/16/20129:55 AMDr. Alteib2004 2005 2006 2007 2008 2009 2010 2011722 720 884 1706 1901 2100 2394 706Sudan (North & South) pre-peace agreementSudan (North & South) / post-peaceagreementSudan (North) / postseparation
  43. 43. ELIMINATION OF LEPROSY In 1991WHOs governing body, theWorldHealth Assembly (WHA) passed a resolutionto eliminate leprosy by the year 2000. Elimination of leprosy is defined as aprevalence rate of less than 1 case per 10 000persons. The target was achieved on time and thewidespread use of MDT reduced the diseaseburden dramatically.12/16/20129:55 AMDr. Alteib
  44. 44. Con.. Over the past 20 years, more than 14 millionleprosy patients have been cured, about 4million since 2000. The prevalence rate of the disease hasdropped by 90% – from 21.1 per 10 000inhabitants to less than 1 per 10 000inhabitants in 2000.12/16/20129:55 AMDr. Alteib
  45. 45. Con.. Dramatic decrease in the global diseaseburden: from 5.2 million in 1985 to 805 000 in1995 to 753 000 at the end of 1999 to 181 941cases at the end of 2011. Leprosy has been eliminated from 119countries out of 122 countries where thedisease was considered as a public healthproblem in 1985.12/16/20129:55 AMDr. Alteib
  46. 46. Con.. So far, there has been no resistance toantileprosy treatment when used as MDT. Efforts currently focus on eliminating leprosyat a national level in the remaining endemiccountries and at a sub-national level from theothers. Early diagnosis and treatment with multidrugtherapy (MDT) remain the key elements ineliminating the disease as a public healthconcern.12/16/20129:55 AMDr. Alteib
  47. 47. Con...WHO STRATEGY FOR LEPROSY ELIMINATIONComponents:ensuring accessible and uninterrupted MDTservices available to all patients through flexibleand patient-friendly drug delivery systemsensuring the sustainability of MDT services byintegrating leprosy services into the generalhealth services and building the ability ofgeneral health workers to treat leprosy12/16/20129:55 AMDr. Alteib
  48. 48. Con..Encouraging self-reporting and earlytreatment by promoting communityawareness and changing the image of leprosyMonitoring the performance of MDT services,the quality of patients’ care and the progressbeing made towards elimination throughnational disease surveillance systems.12/16/20129:55 AMDr. Alteib
  49. 49. Con.. Sustained and committed efforts by thenational programs along with the continuedsupport from national and internationalpartners have led to a decline in the globalburden of leprosy. Increased empowerment of people affectedby the disease, together with their greaterinvolvement in services and community, willbring us closer to a world without leprosy.12/16/20129:55 AMDr. Alteib
  50. 50. Con..ACTIONSAND RESOURCES REQUIRED: In order to reach all patients, leprosytreatment needs to be fully integrated intogeneral health services. Moreover, political commitment needs to besustained in countries where leprosy remainsa public health problem. Partners in leprosy elimination also need tocontinue to ensure that human and financialresources are available.12/16/20129:55 AMDr. Alteib
  51. 51. Con.. The age-old stigma associated with thedisease remains an obstacle to self-reportingand early treatment. The image of leprosy has to be changed atthe global, national and local levels. A new environment, in which patients will nothesitate to come forward for diagnosis andtreatment at any health facility, must becreated.12/16/20129:55 AMDr. Alteib
  52. 52. REFERENCES www.who.int/mediacentre/factsheets/fs101/en/index.html WHO;Global leprosy situation, 2012 WHO;Weekly epidemiological record OXFORD HAND BOOK OF CLINICA MEDICINE DermatologyOnline Journal –Volume 9 - Number 2 /Department of Bioregulation, Leprosy Research Center,National Institute of Infectious Diseases, Higashimurayama,Tokyo, JAPAN, norishii@nih.go.jp12/16/20129:55 AMDr. Alteib
  53. 53. THANKSANDALLTHE BEST12/16/20129:55 AMDr. Alteib