1.
LEPROSY
By
Sriloy Mohanty
B.N.Y.S

2.
Contents…
 introduction

3.
INTRODUCTION
 Chronic infectious disease
 Surface infection
 Caused by M leprae
 Affects mainly the peripheral nerves

4.
Cardinal features
 Hypo-pigmented patches
 Loss of cutaneous sensations
 Thickened nerves
 Presence of acid-fast bacilli in the skin or nasal smear
Signs of advanced disease are:
 Lumps in the skin of the face and ears
 Plantar ulcers
 Loss of fingers or toes
 Nasal depression
 Foot drop and claw toes

5.
History
 Oldest disease known to mankind
 Leper - Greek word – scaly
 Confused with psoriasis, elephantitis and pellagra
 Known as kushta roga
 1873 – Hansen of Norway discovered M. leprae
 1943 – sulphone drugs used in the treatment

6.
Problem Statement
 1991 – WHO Member State resolved to decrease the level
of leprosy by over 90%
 Fall in prevalence rate largely is due to
 Improvement in management of cases
 Low rates of relapse
 High cure rate
 Absence of drug resistance
 Short duration treatment
 WHO global strategy for further reducing the leprosy burden
and sustaining leprosy control activities(2006-10)

7.
 Main elements of the strategy are
 Sustain leprosy control activities in all endemic countries
 Use case detection as the main indicator to monitor
progress
 Ensure high-quality diagnosis, case management, recording
and reporting and reporting in all endemic communities
 Strengthen routine and referral services
 Discontinue the campaign approach
 Develop tools and procedures that are home/community
based, integrated and locally appropriate for the prevention
of disabilities/impairments and for provision of rehabilitation
services
 Promote operational research in order to improve
implementation of a sustainable strategy
 Encourage supportive walking arrangements with partners
at all levels

8.
India
 Leprosy was widely prevalent in India
 Now out of 611 districts,487 are free from leprosy
 A total of 0.87 lakh cases are recorded on 1st April 2008
 Prevalence rate is 0.74 leprosy cases/10,000 population

9.
Epidemiological determinants
 Agent :
 Caused by M. leprae
 They have affinity for Schwann cells and cells of the
reticulo-endocrine system
 The bacterial load is the highest in the lepromatous cases
(2 to 7 billion were estimated in one gram of leproma)
 Phenolic glycolipid (PGL) is the specific M. leprae
 Source of infection
 Multibacillary cases imp source of infection
 All patients with “active leprosy” must be considered
infectious
 Man is the only source and host

10.
 Portal of exit
 Nose is a major portal of exit
 M. leprae are discharged in the nasal mucosa
 Can also exit through ulcerated or broken skin
 Infectivity
 Highly infectious but of low pathogenicity
 Can be rendered non – infectious by treatment of 3 weeks
 Local application of rifampicin can destroy bacilli within 8
days
 Attack Rate
 In households 4.4% to 12% is expected to show signs of
leprosy within 5 years

11.
Host factors
 Age
 Infection can take place at any time depending upon the
opportunity for exposure
 Incidence rates peak between 10 and 20 years of age and
then fall
 A high prevalence of infection among children means that
the disease is active and spreading
 Sex
 Incidence and prevalence higher in males than in females
 Migration
 Mostly a rural problem
 Due to migration it is causing a problem in urban areas also

12.
 Genetic factors
 Human lymphocyte antigen (HLA) linked genes influence
the type of immune response that develops

13.
Environmental Factors
 Humidity favors survival of M.leprae
 Can remain viable in dried nasal secretion at least 9 days
 In moist soil at room temp. for 46 days

14.
Modes of transmission
 Droplet infection
 Aerosols containing M. leprae
 Contact transmission
 Person to person by close contact (direct or indirect)
 Other routes
 Insect vectors
 Tattooing needles

15.
Incubation period
 3 to 5 years or more

16.
Classification
 Three types of classification
 Ridly and jopling classification
 Madrid classification
 Indian Classification
 Indian classification
 Indeterminate type
 Tuberculoid type
 Borderline type
 Lepromatus type
 Pure neuritic type

17.
 Ridly and jopling classification
 Indeterminate type
 Tuberculoid type
 Borderline type
 Lepromatus type
 Pure neuritic type
 Madrid classification
 Indeterminate type
 Tuberculoid type
 Borderline type
 Lepromatus type

18.
Drugs
 Only bactericidal drugs are used
 Rifampicin
 High bactericidal against M.leprae
 Single dose of 1500mg
 3-4 consecutive daily doses of 600mg
 Side-effects are nausea,abdominal pain,vomiting
 Dapsone
 Used all over the world for 30years
 1-2mg/kg of body weight
 Weakly bactericidal effect

19.
 Clofazimine
 Synthesized for treatment of TB
 Found to have greater value against M.leprae
 May give darkish coloration to the skin,urine,sweat
 Ethionamide and protionamide
 Bactericidal drugs killing 98% of M.leprae in 4-5 days
 More expensive and toxic
 Used as the 3rd durgs in multibacillary leprosy

20.
 Quinolones
 Inhibiting DNA synthesis during bacterial replication
 Ofloxacin is most preferable drug in this group
 22 doses of Ofloxacin kill 99.9% of viable M.laprae

21.
WHO Recommeneded
 For adults
 Multibacillary leprosy
 Rifampicin-600mg once monthly
 Dapsone-100mg daily
 Clofazimine-300mg once monthly
50 mg daily
 Paucibacillary leprosy
 Rifampicin-600mg once monthly
 Dapsone-100mg daily for 6 months

22.
 For children 10-14years
 Multibacillary leprosy
 Rifampicin-450mg once monthly
 Dapsone-50mg daily
 Clofazimine-150mg once monthly
50 mg daily
 Paucibacillary leprosy
 Rifampicin-400mg once a day
 Dapsone-50mg daily

23.
Estimation of problem
 Disease load on the community has to be estimated by
surveys
 Prevalence can be determined by examining school –
age children

24.
Diagnosis
 Clinical examination
 Integration
 Collection of bio data
 Family history
 History of contact with leprosy case
 Previous history of treatment
 Present complaint
 Physical examination
 Inspection of skin
 Palpation of commonly involved peripheral and
cutaneous nerve
 Presence of thickening of nerves
 Testing for loss of sensation for heat, cold, pain and
touch in skin patches

25.
 Bacteriological examination
 Skin smears
 Material from the skin obtained from an active
lesion and also from both ear lobes
 Nasal smears
 Best preparation from early morning mucous
material
 Nasal scraping
 Nasal mucosal scrapper is used

26.
Biopsy
 When the examination do not yield diagnosis histo-
pathological examination may be necessary
 It gives an accurate classification of the disease

27.
Immunological tests
 Two types of tests
 Test for detecting cell mediated immunity
 Test for detecting humoral antibodies

28.
Test for CMI
 Lepromin test
 Injecting 0.1ml of lepromin intradermally
 2 types of reaction is seen
 Early reaction
 Late reaction

29.
 Early reaction
 Known as fernandez reaction
 Inflamatory reaction seen in 24-48hrs
 Tends to disappear in 3-4 days
 If the redness is more then 10mm at the end of 48hrs then
the test is considered to be positive
 Indicates previous sensitisation
 Late reaction
 Reaction becomes apperent in 7-8 days
 Maximum in 3-4weeks
 If there is a nodule more then 5mm in diameter then test is
positive

30.
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

31.
Test for humoral response
 FLA-ABS test (Fluorescent Leprosy Antibody Absorption
Test)
 Used to identify sub clinical infections
 It is 92% sensitive and 100% specific in detecting M.leprae
 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

32.
Surveillance
 Paucibacillary leprosy-recomended to be examined
clinically atleast once a year for minimum 2 years
 Multibaccilary leprosy-leprosy-recommended to be
examined clinically at least once a year for minimum 5
years

33.
immunoprophylaxis
 BCG can provide some protection against leprosy
 Several alternative vaccines are under development
 Called as candidate vaccines
 None of them attained “vaccine hood” yet

34.
deformities
 If leprosy not treated at an early stage develops
deformities
 It is due to damage of peripheral nerve trunks or injury
from infection to hand and feet's
 Paralysis may occur to some muscle

35.
Health Education
 Anti-leprosy campaign is incomplete without 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 wrong beliefs and the
social stigma associated with leprosy

36.
Social support
 Chemotherapy alone is not likely to solve this problem
 It needs social support also
 Economic and social problems should be identified

37.
Anti-leprosy activates in India
 1874-Mission To Leprosy was found by Baily at Chamba
in the Himachal Pradesh
 After that a lot of organizations are established
 Hindu Kusth Nivaran Sangha
 Gandhi Memorial Leprosy Foundation
 National Leprosy organization(1965)
 German Leprosy Relief Association
 Damien Foundation
 Danish save the child foundation
 National Leprosy Control Program(1954) was converted
in to Eradication Programme(1983)

38.
Thank you…