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Leprosy

A
Amal Osman

communicable disease course, master of community medicine university of Khartoum

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Communicable diseases
Leprosy
By:
Marwa Gaafar
Objectives:
• Causative agent.
• Background.
• Epidemiology
• Clinical features & complications.
• Diagnosis.
• Reservoir, incubation period & transmission.
• Treatment .
• Control .
• Elimination.
What is leprosy?
 A infectiuos bacterial disease of the skin,
peripheral nerves and mucosa of the upper
airway.
 Chronic, granulomatous.
 Only few from who exposed to infection
develop the disease.
Causative agent:
 Mycobacterium leprae
 Acid fast, rod shaped bacillus
 Stain with Ziehl Neelsen carbol fuchsin.
 cannot be grown in bacteriological media
or cell cultures.
 Present intra and extracellularly, forming
characteristic clumps called Globi.
Background:
 Leprosy has afflicted humanity, left behind a
terrifying image in history and human
memory of mutilation, rejection and exclusion
from society.
 Lots of people have suffered its chronic
course of incurable disfigurement and
physical disability.
Background- discovery
 By G.A. Hansen in 1873.
 First bacterium to be identified as causing
disease in man.
 Treatment only appeared in 1940s (using
promin).

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Leprosy

  • 2. Objectives: • Causative agent. • Background. • Epidemiology • Clinical features & complications. • Diagnosis. • Reservoir, incubation period & transmission. • Treatment . • Control . • Elimination.
  • 3. What is leprosy?  A infectiuos bacterial disease of the skin, peripheral nerves and mucosa of the upper airway.  Chronic, granulomatous.  Only few from who exposed to infection develop the disease.
  • 4. Causative agent:  Mycobacterium leprae  Acid fast, rod shaped bacillus  Stain with Ziehl Neelsen carbol fuchsin.  cannot be grown in bacteriological media or cell cultures.  Present intra and extracellularly, forming characteristic clumps called Globi.
  • 5. Background:  Leprosy has afflicted humanity, left behind a terrifying image in history and human memory of mutilation, rejection and exclusion from society.  Lots of people have suffered its chronic course of incurable disfigurement and physical disability.
  • 6. Background- discovery  By G.A. Hansen in 1873.  First bacterium to be identified as causing disease in man.  Treatment only appeared in 1940s (using promin).
  • 7. Background:  Many countries in Asia, Africa and Latin America with a significant number of cases.  About 1 – 2 million people disabled due to past and present leprosy who need to be cared for by the community.
  • 8. Epidemiology:  Age:  All ages, from early infancy to very old age.  Youngest age reported is 1 and a half months.  Sex:  Both.  Males more than females, 2:1 (equal in Africa)
  • 9. Epidemiology:  Prevalence pool:  Constant flux resulting from inflow and outflow.  Inflow: new cases, relapse, immigration.  Outflow: cure, inactivation, death, emigration.  Global prevalence rate is less than one case per 10,000 persons.  Elimination achieved in 2000.
  • 10. Epidemiology - distribution  Approximately 83% of the leprosy cases live in 6 countries: Nepal, Madagascar, Indonesia, and especially, India and Brazil.
  • 11. Clinical features: 1. Skin : Variable lesions: Macules, papules, nodules. Single / multiple. Hypopigmented, sometimes reddish. Sensory loss typically (anaesthesia/hypothesia).
  • 12. Clinical features: 2. Nerves : Thickened. Loss of sensation. Muscle weakness.
  • 13. Mechanism of Nerve Damage Scollard, DM et al. 2006. “The continuing challenges of leprosy.” Clinical microbiology reviews 19, no. 2: 338-81. 1.Entry Through Blood Vessels 2. Inflammatory Response 3. Demyelination
  • 18. International Federation of Anti-Leprosy Associations (ILEP) http://www.ilep.org.uk/en/ Sensory Loss Can Lead to Secondary Infections and Severe Deformities
  • 19. Diagnosis:  Mainly clinical, based on signs and symptoms.  Laboratory: Positive skin smears/ nasal smears/scrapings.  lepromin test.
  • 20. Lepromin test:  Used to determine type of leprosy.  Injection of a standardized extract of the inactivated bacilli intradermally in the forearm.  Positive reaction: 10 mm or more induration after 48 hrs/ or 5 mm or more nodule after 21 days.  Negative In lepromatous leprosy because of humoral immunity not cell mediated.
  • 21. What is not leprosy !!  Skin patches which  have normal feeling  are present from birth  cause itching  are white, black, dark red or silver coloured  show scaling  appear and disappear periodically  spread quickly
  • 22. What is not leprosy (cont.)  Signs of damage to hands/feet/face without loss of sensation  due to other reasons like injury, accidents, burns, birth defects  due to other diseases like arthritis  due to other conditions causing paralysis
  • 23. Case definition (WHO operational definition)  Is a person having one or more of the following, who has yet to complete a full course of treatment:  Hypopigmented or reddish skin lesion(s) with definite loss of sensation  Involvement of the peripheral nerves (definite thickening with loss of sensation)  Skin smear positive for acid-fast bacilli.
  • 24. Classification:  Based on:  Skin smear results, or number of skin lesions. 1. Paucibacillary leprosy 2. (PB) Multibacillary leprosy (MB 3. Borderline leprosy- between the two.  Differ in treatment regimen.
  • 25.  Tuberculoid leprosy  less than 5 patches of skin lesions.  Skin tests with lepromin elicit a strong positive response  Lesions bacteriologically negative.  strong cell-mediated responses.  peripheral nerves damaged by host’s immune response. Classification of leprosy
  • 26.  Lepromatous leprosy:  Numerous poorly defined lesions.  Symmetrical distribution.  Positive smear test. Classification of leprosy
  • 27.  Borderline leprosy:  Four or more lesions .  Well or ill defined.  Bacteriologic positivity is variable.  If not treated, progresses to lepromatous type.  If severe, treated with corticosteroids. Classification of leprosy
  • 28.  Immunologically mediated episodes of inflammation.  Can affect peripheral nerves causing deformities.  Diagnosed clinically.  Not due to treatment. Leprosy reactions
  • 29.  Type 1 (reversal reaction)  Delayed hypersensitivity reaction.  In both pauci/multibacillary.  Recurrent.  Inflammation in skin lesions and nerves (nuritis).  Lesions: edema , ulcer. Leprosy reactions
  • 30.  Type 2 (erythema nodosum leprosum)  Humoral response.  Only in multibacillary.  Red , painful subcutaneous nodules  In face, arms, legs bilaterally symmetrical.  Neuritis also occurs.  Serious, diffficult to manage. Leprosy reactions
  • 31. Transmission- route  Exactly unknown.  Contact with cases. Which contact?! (intimate, repeated, skin to skin…. Household contact easily identifed)….related to dose of infection.  Respiratory route, possibility is increasing.  Biting Insects, questionable.  Organisms exit thro skin & nasal mucosa.  Entry: skin (broken-tattooing needle), respiratory tract (propable)
  • 32. Transmission - reservoir  Human being, only known.  Similar organisms detected in wild armadillo.  History of handling armidellos reported.
  • 33. Transmission - survival  M.leprae from nasal secretions up to 36 hrs.  Also reported in nasal secretions up to 9 days.  So contaminate clothing and other fomites.  Infectivity only 1 day after starting treatment.
  • 34. Incubation period  From 9 months to 20 years.  Average 4 years for tuberculoid leprosy and twice that for lepromatous leprosy.
  • 35. Treatment  In 1941, promin introduced,but painful injections.  In 1950s, Dapsone pills, but resistance developed.  In 1981, WHO recommends multi drug treatment (MDT): Dapsone, Rifampicine, Clofazimine  Patients under treatment should be monitored for drug side-effects, leprosy reactions and for development of trophic ulcers
  • 36. 1981: WHO Proposes Multi- Drug Therapy (MDT)  Combination of DAPSONE, RIFAMPICIN, and CLOFAZIMINE + +
  • 37. Treatment - regimen  Adults with multibacillary,MDT for 12 months:  Rifampicine 600 mg once a month  Dapsone 100 mg once a day  Clofazimine: 50 mg once a day and 300 mg once a month.  Adults with paucibacillary:  Rifampicin: 600 mg once a month  Dapsone: 100 mg once a day.
  • 38. Steps to start MDT  Classify as PB or MB leprosy  Inform patient about the disease .  Explain the MDT blister pack - show drugs to be taken once a month and every day  Explain possible side effects (e.g. darkening of skin) and possible complications and when they must return to the health centre  .Give enough MDT blister packs to last until the next visit.  Fill out the patient treatment card
  • 39. Treatment – drug presentation
  • 40. 1995: WHO Distributes MDT Drugs for Free to Worldwide Patients
  • 42. Some patients may develop complications  Leprosy reactions  Side-effects  Disabilities
  • 43. Leprosy reactions  1 or 2 patients in 10 may develop reactions  Reactions are not a side effect of MDT. They are the body’s response to leprosy  More commonly seen in MB cases  Signs and symptoms include  Skin: patch/s becomes reddish and/or swollen; sometimes painful reddish nodules appear  Nerves: pain in the nerve and/or joint; loss of sensation and weakness of muscles (commonly of hands, feet and around eyes)  General: fever, malaise, swelling of hands/feet
  • 44. Managing reactions  Early diagnosis and prompt treatment of reactions  Every patient should be informed about the signs and symptoms of reactions  Inform them to go as soon as possible to the health centre  Reassure patients that:  reactions can be treated  they are not a side-effect to MDT  does not mean that MDT is not working
  • 45. Managing reactions  Rest is very important:  Help to get leave from work or school for a few days (e.g. medical certificate)  Control of pain and fever  Aspirin or paracetamol  Continue MDT regularly
  • 46. Managing reactions  Reactions which only involve the skin:  rest and pain-killers are usually sufficient.  If there is no improvement within few days or worsening, then specific treatment is needed  Reactions which involves the nerves  start treatment with a course of corticosteroids (e.g. prednisolone) as soon as possible  will control all signs/symptoms of reaction
  • 47. MDT side-effects  Red coloured urine  Darkening of skin  Severe itching of skin  This is due to rifampicin. Lasts only for few hours Reassure the patient that this is harmless  This is due to clofazimine. Reassure the patient that this will disappear after treatment is completed  This is due to allergy to one of the drugs (commonly to dapsone). Stop all medicines and refer to hospital
  • 48. Treatment of disability  Why disability occur??  Late diagnosis and late treatment with MDT  Advanced disease (MB leprosy)  Leprosy reactions which involve nerves  Lack of information on how to protect insensitive parts
  • 49. Treatment of disability  The best way to prevent disabilities is: early diagnosis and prompt treatment with MDT  Inform patients (specially MB) about common signs/symptoms of reactions.  Ask them to come to the centre  Start treatment for reaction, Inform them how to protect insensitive hands/ feet /eyes  Involve family members in helping patients
  • 50. Care of feet  Cracks and fissures  Blisters  Simple ulcer  Soak in water  Apply cooking oil/Vaseline  Use footwear  Do not open blister  Apply clean bandage  Clean with soap & water  Rest and clean bandage
  • 51. Care of feet  Infected ulcer  Wounds/injury  Weakness/paralysis  Clean with soap & water  Rest & apply antiseptic dressing  Soak in water  Apply cooking oil/Vaseline  Clean and apply clean bandage  Protect when working/cooking  Oil massage  Exercises  Refer
  • 52. Care of eyes  Redness and pain  Injury to cornea  Difficulty in closing eye  Aspirin or paracetamol  Atropine and steroid ointment  Cover with eye pad  Apply antibiotic ointment  Refer  Tear substitute eye drops  Exercises  Dark glasses to protect  Refer
  • 53. Treatment – post completion  Congratulate the patient  Thank family/friends for their support  Reassure that MDT completely cures leprosy  Any residual lesions will fade away slowly  Show them how to protect anaesthetic areas and/or disabilities  Encourage to come back in case of any problem  Tell that they are welcome to bring other members of family or friends for consultation
  • 55. Control 1. Preventive measures. 2. Control of cases, contacts and immediate environment. 3. Disaster implications.
  • 56. Control – preventive measures  Early dtection and treatment of cases.  Health education and counselling must stress on the availability of effective therapy, the absence of infectivity of patients under treatment and prevention of physical and social disabilities.
  • 57. Control – preventive measures  BCG vaccination for tuberculoid leprosy; this as part of T.B. control , not be undertaken specifically to prevent leprosy, it provides variable levels of protection.  Currently, no single vaccine that confers complete immunity in all individuals.
  • 58. Control of patient, contacts and the immediate environment: 1. Report to local health authority. 2. Isolation: is of questionable value and can lead to stigmatization. No restrictions in employment or attendance at school are indicated. 3. Quarantine: Not applicable. 4. Immunization of contacts: Not recommended 5. Investigation of contacts and source of infection. 6. Specific treatment: MRT
  • 59. Control : disaster implications  Any interruption of treatment schedules is serious.  During wars, diagnosis and treatment of leprosy patients has often been neglected.
  • 60. Elimination  Leprosy meets the demanding criteria for elimination: - Practical and simple diagnostic tools: can be diagnosed on clinical signs alone; - Availability of an effective intervention to interrupt its transmission: multidrug therapy - A single significant reservoir of infection: humans.
  • 61. 1999: Global Alliance to Eliminate Leprosy As a Public Health Problem
  • 62. Elimination strategy  Providing MDT to all communities  Breaking the chain of transmission by intensive case detection and prompt treatment  Improving quality of patient care, including disability prevention and management  Ensuring regularity and completion of treatment  Encouraging and ensuring community participation  Providing rehabilitation to the needy patients  Organising health education to patients , their families and community
  • 63. Obstacles to Eliminating Leprosy in Endemic Countries . STIGMA
  • 64. Overcoming Stigma  Mass Media  Integrated Primary Health Services  Education & Training
  • 65. Worobec, Sophie M. 2009. “Treatment of leprosy/Hansen's disease in the early 21st century.” Dermatologic therapy 22, no. 6: 518-37.
  • 66.  Sudan achieved the elimination level, nevertheless incidence of new cases is rising, reporting between 300-900 cases per yr.  Some districts has not achieved elimination, also in egypt and yemen.  South sudan is the only in eastern mediterranean region that reports more than 1000 new cases per yr.