2. 2
Presented By:
Dr. Ravi Prakash
JR-II
Department of Community Medicine
Katihar Medical College, Katihar
3. CARDINAL FEATURES
Hypo-pigmented patches
Partial or total loss of cutaneous sensation in the affected
area (light touch is the earliest sensation to be lost)
Presence of thickened nerves
Presence of acid-fast bacilli in the skin or nasal smear
3
Clinical Signs & Symptoms
10. SIGNS OF ADVANCED DISEASE:
Lumps or nodules in the skin of the face and ears
Plantar ulcers
Loss of fingers or toes
Nasal depression
Foot drop and claw toes
Other deformities
10
16. NERVE INVOLVEMENT:
leads to muscle weakness, muscle atrophy, severe neuritic pain,
and contractures of the hands and feet.
Ulnar nerve is most commonly involved , least common is
radial.
Most common cranial nerve involved is Trigeminal.
First sensation to go is thermal (cold>fine
touch). Proprioception is usually preserved. 16
34. DONE BY:
History & Clinical examination
Bacteriological examination:
By: skin smears, nasal smears or blows, nasal scrappings
Foot pad culture
Histamine test
Biopsy 34
Diagnosis
35. Immunological Test:
(A) Tests For Detecting Cell Mediated Immunity
Lepromin test
Lymphocyte transformation test (LTT)
Leucocyte migration inhibition test(LMIT)
(B) Tests For Humoral Response To M.Leprae
Flourescent leprosy antibody absorption test
(FLA-ABS)
Monoclonal antibodies
ELISA – based on Phenolic glycolipid antigen (PGL) 35
36. HISTORY:
Patients Bio data : name, age, sex, address
Presenting complaints
Family history of leprosy
Contact with leprosy cases
Previous history of treatment for leprosy, if any
CLINICAL EXAMINATION:
A thorough inspection of the body surface(skin).
Palpation of commonly involved superficial nerves.
36
37. Ulnar N. near the medial epicondyle.
Greater Auricular N as it turns over SCMmuscle.
Lateral Popliteal N.
Dorsal branch of Radial N.
TESTING FOR :
Loss of sensation : heat, cold, pain, touch .
Paresis or paralysis of muscles of hands and feet.
37
39. BACTERIOLOGICAL EXAMINATION:
Skin Smears :
Simple and valuable test.
It is needed for diagnosis.
Monitor the progress of the treatment
Pinch the site tight, Incise, Scrape & collect material
Smear on a slide, Air dry & fix, Stain (Z-N method)
Sites are: Ear lobe, Forehead, Gluteal region, Active edge of
patch.
39
40. NASAL SMEARS OR BLOWS :
Nasal smears can be best prepared from early morning mucus
material.
Nasal Scrapings :
After going in 4.5 cm the blade is rotated towards the septum
and scrapped a few times and withdrawn.
BACTERIAL INDEX:
It is the only objective way of monitoring benefit of treatment.
It indicates the density of leprosy bacilli in smears and includes both
living (solid staining) and dead (fragmented or granular) bacilli.
40
41. According ToRidley’s Logarithmic Scale, It Ranges From 0To 6+
and is based on the no. of bacilli seen in an average microscopic field.
B 0 stands for no bacilli in any of 100 oil immersion field.
41
43. MORPHOLOGICAL INDEX:
The MI is calculated after examining 200 pink-stained free
standing bacilli.
The percentage of solid staining bacilli in a stained smear is referred
to as MI.
It is a valuable indicator of the patient’s response to treatment during
the first few months and helps to signal drug resistance.
SOLID FRAGMENTED GRANULAR(SFG) PERCENTAGE:
It gives a better picture as solid fragmented and granular bacilli are mentioned
separately. It is similar to MI but a more sensitive indicator of the patient’s
response to treatment.
43
44. FOOT-PAD CULTURE:
Only certain way of identifying M. Leprae is to inoculate the
material into foot pads of mice and demonstrate its multiplication
10 times more sensitive at detecting the bacilli than slit skin smear.
Time consuming : requires 6 to 9 months.
Used for :
1. Detecting drug resistance.
2. Evaluating the potency of anti-leprosy drugs.
3. Detecting the viability of bacilli during treatment.
44
45. HISTAMINE TEST:
Reliable test for detecting at an early stage peripheral nerve
damage due to leprosy.
Method : carried out by injecting 0.1ml of a 1:1000 solution of
histamine phosphate into hypopigmented patches or in areas of
anesthesia.
Result : in normal person it gives rise to a wheal surrounded by
erythematous flare(Lewis triple response). In case of leprosy where
the nerve supply is destroyed, flare response is lost.
50
45
46. BIOPSY:
Usually resorted to when there is high clinical suspicion but the other
test are unyielding. It also gives information about the bacterial
content of skin.
IMMUNOLOGICAL TESTS:
LEPROMIN TEST
Test of cell mediated immunity
METHOD : it is performed by injecting 0.1ml of lepromin into inner
aspect of the forearm. The reaction is read at 48 hours and 21 days.
Two types of reaction have been described :
46
47. ANTIGENS USED:
Dharmendra antigen
Mitusda antigen
EARLY REACTION (FERNANDEZ REACTION) :
An inflammatory reaction develops within 24 to 48 hours and this tends to
disappear in 3 to 4 days. If the diameter of the red area is more than 10mm
the test is considered positive.
It is a delayed type hypersensitivity reaction indicating prior exposure
or infection to soluble constituents of lepra bacilli.
Superior to late reaction
47
48. LATE REACTION (MITSUDA REACTION) :
It is characterized by the appearance of a nodule which becomes
apparent in 7 to 10 days and reaches its maximum in 3 to 4 weeks.
The test is read at 21 days.
If the nodule is more than 5 mm it is considered positive.
It is induced by the bacillary component and indicates cell mediated
immunity.
In the first six months of life most children are lepromin
negative. BCG vaccination is capable of converting lepra
reaction from negative to positive.
48
49. VALUE OF LEPROMIN TEST :
Evaluating the immune status of leprosy patients.
Aid to classify the type of disease.
Estimating the prognosis
Strongly positive in a typical tuberculoid case and getting weaker
towards the lepromatous end, the typical lepromatous case being
lepromin negative indicating failure of CMI.
The greatest drawback being:-
Positive in non cases
Negative in lepromatous cases hence not used as a diagnostic test.
49
50. LTT & LMIT :
Newer in in vitro tests such as lymphocyte transformation test and
leucocyte migration inhibition test has been developed
They give a measure of CMI
Used to detect sub clinical infection
FLA-ABS TEST :
Tests for humoral antibodies(serological tests)
used for detecting subclinical infections. 92.3 percent sensitive and 100
percent specific in detecting specific antibodies in all types leprosy
irrespective of type and duration of disease.
50
51. MONOCLONAL ANTIBODIES
These against M. leprae antigens have been produced
If antibodies against specific antigens are found, they will
become reagent of choice for identifying M. Leprae
ELISA TEST- based on a phenolic glycolipid (pgl)antigen
51
52. MEDICAL MEASURES
ESTIMATION OF THE PROBLEM
EARLY CASE DETECTION
MULTIDRUG THERAPY
SURVEILLANCE
IMMUNOPROPHYLAXIS
CHEMOPROPHYLAXIS
DEFORMITIES REHABILITATION
HEALTH EDUCATION
SOCIAL SUPPORT
PROGRAMME MANAGEMENT
EVALUATION
52
Leprosy Control
54. MULTI DRUG THERAPY
In the absence of effective primary prevention by a leprosy vaccine
leprosy control is based on effective multidrug chemotherapy(secondary
prevention).
OBJECTIVES :
Tointerrupt transmission of infection
Early detection and treatment of cases to prevent deformities
Toprevent drug resistance
54
Treatment
57. IMPORTANT POINTS :
MDT is not contraindicated in patients with HIV infection.
MDT is safe during pregnancy.
Drugs are excreted in breast milk but no reports of
adverse reaction except for mild discoloration of infants
skin by clofazimine
Leprosy is exacerbated during pregnancy, it is important
that MDT is continued
57
58. SURVEILLANCE:
Paucibacillary leprosy- recommended to be examined
clinically atleast once a year for minimum 2 years
Multibaccilary leprosy- recommended to be examined
clinically at least once a year for minimum 5 years.
IMMUNOPROPHYLAXIS:
BCG can provide some protection against leprosy
Several alternative vaccines are under development
58
59. DEFORMITIES:
It is due to damage of peripheral nerve trunks or injury from
infection to hand and feet's
Approx. 25 percent of cases who are not properly treated at
an early stage develop deformities of hands and feet.
DEFORMITIES PREVENTION:
Measures include care of dry and denervated skin of palms
and soles.
Treating wounds, ulcers, and cracks in palms & soles
Use of protective gloves and footwear
59
67. REHABILITATION
Rehabilitation includes all the measures used for reducing
the impact of disability for an individual, enabling
him/her to achieve independence, social integration, a
better quality of life and self actualization.
67
70. GRIP AIDS
• Indications –Grossly deformed hand with loss of fingers, fixed
contractures, loss of sensory input, total fixed claw hand
• Made up of – epoxy resin putty grip aids
•Fitted to any tool / utensils
• Adheres to any surface
• Washable and autoclaved
• Improve grip & protect skin from abrasion and ulcer
• Improves quality of life
• Disadvantage – not suitable for heating
70
72. HEALTH EDUCATION
Health education aims at helping people to avoid this type
of diseases.
It should be direct towards the patient and his/her family.
It should educate people on the true facts about leprosy
and removes superstation and the social stigma associated
with leprosy.
SOCIAL SUPPORT
Chemotherapy alone is not likely to solve this problem
It needs social support also. 72
73. During the course of leprosy, immunological mediated
episodes of acute or subacute inflammation known as
reaction may occur.
There are two types of reactions :
Type 1 or Reversal reaction
Type 2 or erythema nodosum leprosum
Both types can occur before the start of MDT, during
treatment or after completion of treatment.
73
Lepra Reaction
74. REVERSAL REACTION
The leprosy skin lesions themselves become inflamed red,
swollen and painful.
It is type of delayed type of hypersensitivity.
Occurs in both PB and MB
Nerves may be enlarged, tender and painful with loss of
function.
General symptoms are uncommon
Do not affect other organs.
74
75. ERYTHEMA NODOSUM LEPROSUM
In ENL new inflamed, red nodules appear under the skin,
while the original lesions remain same.
Commonly on face, arm and legs & bilaterally symmetrical.
subside within few days even without treatment
It is antigen antibody reaction.
Seen in MB cases only.
Nerves may be affected but is uncommon
Other organs like testis, eye, kidney may be affected
General symptoms of fever, joint pain, red eyes and watering
may be associated.
75
77. TREATMENT
Because of high risk of permanent nerve damage reversal
reaction needs to be promptly diagnosed and treated
adequately
Standard 12 wk. regimen of prednisolone is the treatment of
choice.
Treatment also includes bed rest, splinting of affected nerves,
analgesics and prednisolone.
77
79. ANTI-LEPROSY ACTIVITIES IN INDIA
1874-Mission To Leprosy was found by Baily at Chamba in the
Himachal Pradesh. (now in Purulia in West Bengal)
After that a lot of organizations are established
Hindu Kusth Nivaran Sangha
Gandhi Memorial Leprosy Foundation
National Leprosy organization(1965)
German Leprosy ReliefAssociation
Damien Foundation
Danish save the child foundation
National Leprosy Control Program(1955) was converted in to
Eradication Programme(1983)
79
80. MILESTONES OF LEPROSY ERADICATION
• 1898 – Leper act Later abolished by British india
• 1948 – Hind Kush Nivaran Sangh
• 1955 – National leprosy control program
• 1982 - MDT
80
81. • 1983 – National leprosy eradication program
(MDT started)
• 1991 – World health assembly resolution to
eradicate leprosy by 2000.
• 1993 – World bank supported the MDT
program phase NLEP 1
81
83. • 2005 December – Prevalence rate 0.95/10,000
and Govt declared achievement of elimination
target.
• 2005 – NRHM covers NLEP
83
84. NLEP
NLEP was launched on 1983
The NLEP is a centrally sponsored health scheme of the
Ministry of Health and Family Welfare, Govt. of India
The programme is headed by the deputy director of health
services(Leprosy) under the administrative control of the
Directorate General Health Services, Govt. of India
The programme is also supported as partners by
WHO
The International Federation of Anti-leprosy Associations
Non-Govt. Organizations
84
85. THE EMBLEM
The NLEP Emblem symbolizes
Beauty and purity in lotus
Leprosy can be cured and a
leprosy patient can be a useful
member of the society in the
form of a partially affected
thumb
Normal fore-finger
representing the shape of a
house
The symbol of hope and
optimism in a rising sun
The emblem captures the
spirit of hope positive action
in the eradication of Leprosy
85
86. CURRENT ACTIVITIES UNDER NLEP
Diagnosis and treatment of leprosy
• MDT provided to all PHCs free of cost .
• Difficult to diagnose cases & complicated
cases referred to district hospitals.
• ASHAs under NRHM helps bring out
leprosy cases from villages for diagnosis and
treatment completion. 86
87. Training
Training to Medical officers, health workers,
lab technicians, ASHAs conducted every year
• Training of state & district Leprosy officers
organized at Schieffline institute of health
research & leprosy centre Vellore, TN and
RLTRI Raipur
87
88. Involvement of NGOs
• Help reduce burden of leprosy.
• Serve in remote, inaccessible, uncovered,
urban slums, industrial/labour populations
and other marginalised population groups.
88
89. Information, education & communication
• IEC help reduction of stigma & discrimination
against leprosy affected persons.
• Carried out through mass media, out door
media, rural media & advocatory meetings.
• More focus on inter personal communication
89
90. Disability prevention and medical
rehabilitation.
• Patients provided with dressing materials,
supportive medicines & MCR footwear
• Correction of disability through reconstructive
surgery 90
92. Urban leprosy control
• Implemented in 422 urban areas with
population size more than 1 lakh
• Includes MDT delivery services & follow up of
patients with treatment completion, providing
supportive medicines and dressing materials.
92
93. Monitoring & Supervision
• By analysis of monthly progress reports,
through field visits by supervisory officers, and
programme review meetings held at central,
State & District levels.
93
94. NEW INITIATIVES
Reconstructive surgery
• Amount of Rs 5000 provided as incentive to
leprosy patients from BPL families for
undergoing major reconstructive surgeries in
identified Govt/NGO institutions
94
95. Involvement of ASHAs
• Incentives provided for ASHAs for bringing out
cases from their villages.
• Rs 100 for confirmed diagnosis of cases.
• On completion of treatment within specified
time Rs 200 for PB & Rs 400 for MB.
95
96. Special activities in High Endemic areas
• Involves training, intensified IEC, case
detection & prompt MDT through health care
staff
96
97. National sample survey
• By National JALMA Institute, Agra
• Started in 2010.
• House to house survey to access the burden of
active leprosy cases, leprosy persons with
grade 1 & 2 disability and magnitude of stigma
and discrimination in society.
97
98. Budget and international support
• Since 2005, the program is being conducted
with Govt of India funds with technical
support from WHO & International federation
of anti leprosy association(ILEP)
98
99. OFFICIALS/ STAFF ATTACHED TO DISTRICT LEPROSY
ORGANISATION
• Deputy Director of Medical Services (Leprosy)
• Medical Officer- Deputy Director (Leprosy)
• Health Educator
• Non Medical Supervisor
• Physio Technicians
• Health Inspectors
• Lab technician
99
100. ANTI LEPROSY ACTIVITIES IN INDIA
• Leprosy Mission - founded in 1874 in H.P.
• Hind Kush Nivaran Sangh
• Gandhiji Memorial Leprosy Foundation,
Sevagram, Wardha
• The German Leprosy Relief Association
• Damien Foundation
• The Danish Save the Child Fund
• JALMA- taken over by ICMR in 1975
• National Leprosy Organisation- 1965
100
103. REFERENCE
1. National leprosy eradication programme,Annual
report (2015-16), M/O H&FW, Govt of India.
2. National leprosy eradication programme,Annual
report (2014-15), M/O H&FW, Govt of India.
3. Health Policies and Programs in India,
D.K.Taneja
4. National Health programs of India, J.Kishore
5.IAL Textbook of Leprosy,
6.Park’s Textbook of Preventive and Social Medicine
, K.Park, 25th edition. 103
104. “LEPROSY WORK IS NOT MERELY
MEDICALRELIEF;
it is transforming frustration of life into joy of
dedication, personal ambition into selfless service...”
MahatmaGandhi
THANK YOU
104
