Lepr Rev (2014) 85, 296 310

Childhood leprosy through the post-leprosy-

elimination era: a retrospective analysis of
epidemiological and clinical characteristics of
disease over eleven years from a tertiary care
hospital in North India

SUNIL DOG RA* , TA RUN NARA NG*

,
GEET I KHUL LAR * , R AMES H K UMA R *
& UMA NAH AR SA IKIA**
*Departments of Dermatology, Venereology and Leprology and
**Histopathology, Postgraduate Institute of Medical Education and
Research, Chandigarh, India

Accepted for publication 21 October 2014

Summary
Background: Children are believed to be the most vulnerable group for leprosy
and childhood leprosy reflects disease transmission in the community as well as the
efficiency of ongoing disease control programmes.
Objectives: To study the epidemiological and clinical trends of childhood cases of
leprosy at a tertiary care hospital in North India during 2001
2011.
Methods: A retrospective study was undertaken analysing the clinic records of
children with leprosy less than or equal to 18 years registered at the leprosy clinic
of this institute over an 11- year period. Demographic and disease characteristics
including age, sex, history of contact, duration of disease, clinical pattern,
bacteriological and histopathological parameters, reactions and disabilities were
noted from a predesigned format.
Results: A total of 1225 cases of leprosy were registered during this period, of
whom 59 (481%) were children. The mean age of the patients was 1006 ^ 335
years with a male preponderance (39:1). History of close contact with a leprosy case
was present in 15 (254%) patients. Mean duration of illness before diagnosis was
185 months (range: 1 70 months). Borderline tuberculoid (BT) was the
commonest clinical type in 40 children (678%), followed by lepromatous (LL) in
7 (119%), borderline lepromatous (BL) in 6 (101%), pure neuritic (PNL) in
2 (34%), tuberculoid (TT), mid-borderline (BB), histoid and indeterminate leprosy
in 1 patient (17%) each. Lesions were located over upper extremity in 32
(542%), lower extremity in 29 (492%), face in 27 (458%) and trunk in 26 (441%)
patients. A single lesion was observed in 23 (39%), 2 5 lesions in 12 (203%)
and more than five

Correspondence to: Sunil Dogra, Department of Dermatology, Venereology and Leprology, Postgraduate
Institute of Medical Education and Research, Chandigarh, India (e-mail: sundogra@hotmail.com)
296 0305-7518/14/064053+15 $1.00 q Lepra
297 S. Dogra et al. Childhood leprosy in North India 297
lesions in 22 (373%) children. The slit skin smear was positive in 17 (288%)
patients. Lepra reactions were observed in 20 patients (339%), of whom 14 (70%)
had Type 1, and six (30%) had Type 2 lepra reaction. Thickened peripheral nerve
trunks were present in 48 (814%) children, of which, 27 (563%) had more than one
thickened nerve and 21 (437%) had only a single nerve involved. Neuritis occurred
in 9 (153%) and disability (both grade 1 and 2) at the time of diagnosis was noted
in 24 (407%) patients. Six (102%) children defaulted from treatment. Three cases
(51%) of relapse were observed.
Conclusions: Childhood leprosy cases and their complications continue to present
in alarming numbers in India and this suggests possible gaps in the national
programmes aimed at leprosy elimination. We stress the importance of continuous
and sustained efforts for early case detection in the community in general, and close
follow-up of susceptible children amongst household contacts of leprosy cases in
the post-leprosy-elimination era.

Introduction

Although India attained the goal of leprosy elimination in December 2005, it still
contributed
1
4854% of total leprosy cases detected worldwide in the year 2012 13. Close and
prolonged contact with intra-familial sources of infection exposes children to high risk of
acquiring infection and manifesting disease as a consequence of their weak immune
response. The child
proportion refers to the percentage of children among all new cases of leprosy detected
during a given year. It is an important epidemiological indicator as it reflects active
disease transmission in the community and the operational efficiency of a given leprosy
elimination program. In the South- East Asia Region, 16,337 new cases of childhood
1
leprosy were detected in 2012, of which 13,387 (819%) were from India. Children
accounted for 993% [317% multibacillary (MB) and 677% paucibacillary (PB)] of the
2
new leprosy cases detected during 2012 13 in India.
The present study was undertaken to analyse the clinico-epidemiological data of
childhood leprosy cases over eleven years from our centre.

Patients and methods

This study was a retrospective analysis of all cases # 18 years of age registered at the
leprosy clinic of our Institute (January 2001 to December 2011), a tertiary care teaching
hospital in Northern India, which caters to the population from Punjab, Haryana, Himachal
Pradesh and neighbouring cities of Uttar Pradesh, besides the migrant population from all
parts of India. Many patients with leprosy are self-referred and some are referred by other
doctors or clinics. No active surveys in the community were undertaken for case
detection. Details of age, sex, state of origin, duration of symptoms, source of contact and
clinical findings extracted from clinic files were analysed. Clinical data included the number
and distribution of lesions, the pattern of nerve involvement and the presence of lepra
reactions, neuritis and disabilities. Slit skin smear (SSS) examination was done prior to
the start of treatment and then
6 monthly, while a skin biopsy taken at baseline and at the end of treatment. Depending on
the number of lesions, their morphology, distribution and related nerve involvement, patients
were classified according to the Ridley-Jopling spectrum as tuberculoid (TT), borderline
 3
tuberculoid (BT), mid-borderline (BB), borderline lepromatous (BL) and lepromatous (LL).
Some patients were also classified as indeterminate or pure neuritic leprosy (PNL), when
applicable.
The parameters used for histopathological correlation were epidermal thickness, presence
or absence of a grenz zone, predominant type of granuloma (foamy macrophage or
epithelioid) and whether ill or well-defined, proportion of lymphocytes, giant cells,
perineural and periappendageal infiltrate, with or without destruction of nerves and
appendages, and bacillary load on modified Fite- Faraco staining.
Type 1 lepra reaction was diagnosed if the patient had redness, swelling or tenderness
of pre-existing lesions, with or without the appearance of new lesions, presence of oedema
of hands, feet or face or tenderness of one or more nerves, with or without nerve function
4
impairment (NFI). Type 2 lepra reaction was diagnosed if the patient had multiple, small,
tender, evanescent nodules or plaques, with or without constitutional symptoms such as
4
fever, malaise, lymphadenitis and myalgia.
Disabilities were classified according to the standard WHO grading system.5 Grade 1
disability included glove and stocking anesthesia and Grade 2 disability included claw hand,
foot drop, trophic ulcers, resorption of digits, guttering of interosseous spaces, redness in
eyes, inability to close eyes and visual impairment.
Treatment administered, adherence, number of defaulters and relapses were also studied.
All patients with a positive SSS for acid fast bacilli (AFB), having more than five skin
lesions, with involvement of two or more distant body parts, more than one involved
peripheral nerve trunk (excluding the draining nerve) or falling in the BB, BL and LL
spectrum were classified as MB and treated with 12 months of WHO multidrug therapy-
multibacillary regimen (MDT- MBR). The remaining patients were given WHO multidrug
therapy-paucibacillary regimen (MDT-PBR). The monthly dose was supervised. The
diagnosis of relapse was made in accordance with the WHO definition: a patient who
successfully completes an adequate course of multidrug therapy, but who subsequently
develops new signs and symptoms of the disease, either during the surveillance period (2
6
years for PB and 5 years for MB leprosy) or thereafter.

14
Child proportion (%)
12

10

0
2002 2001

Figure 1. Year-wise proportion of childhood leprosy cases.

Results

The number of new cases of leprosy registered during the study were 1225 and of these, 59
were children with an 11-year average child proportion of 481%. Year-wise proportion of
childhood leprosy cases is depicted in Figure 1.
The clinico-epidemiological profile of the patients is given in Table 1.

DEMOGRA P HICS

A majority of the children, [35 (593%)] were in the age group 11 14 years, followed by 16
(271%) in the 6 10 years group and seven (119%) in the 15 18 years group. The
youngest

Table 1. Demographic and clinical profile of 59 children with leprosy

Clinico-epidemiological parameters Number of patients (%)

Age group (years)

,1 1 (17)
6 10 16 (271)
11 14 35 (593)
15 18 7
(119) Sex ratio (M:F)
39:1
Duration of symptoms at presentation
, 1 year 21 (356)
1 5 years 34 (576)
. 5 years 4 (68)
Close contact with a known leprosy case 15 (254)
Familial 13 (22)
Non familial 2 (34)
Number of lesions
Single 23 (39)
2 5 12 (203)
.5 22
(373) Peripheral nerves involved 48
(814) Single 21
(356) Multiple 27
(458) SSS positivity 17
(288)
BI , 2 5 (85)
BI $ 2 12 (203)
MI Positivity 12 (203)
Classification
MB 31 (525)
PB 28 (475)
Clinico-histopathological correlation 45 (763)
Reactions 20 (339)
Type 1 14 (237)
Type 2 6 (102)
Disabilities* 24 (407)
Grade 1 5 (85)
Grade 2 19 (322)
Claw hand 15 (254)
Foot drop 2 (34)
Trophic ulcers 2 (34)

*
A given patient may have had more than one disability
patient was 9 months old. The mean age of the group was 1006 ^ 335 years. There were
47 boys and 12 girls (ratio 39:1).The mean duration of symptoms was 185 months (range: 1
70 months). BCG scar was present in all the children. A majority of our patients (525%)
were migrants from northern states of Uttar Pradesh and Bihar. A history of close contact
with a leprosy case was present in 15 patients (254%), of whom 13 (22%) were household
contacts and only 2 (34%) were extra-familial contacts. The most common familial contact
was with a parent, followed by siblings and grandparents.

CL INI C AL F I N D
INGS

The most common clinical diagnosis according to the Ridley-Jopling classification was BT
(Figures 2 4), in 40 (678%) patients, followed by LL in 7 (119%), BL in 6 (101%),
pure neuritic in 2 (34%) and TT and BB in 1 (17%) patient each.
Indeterminate and histoid leprosy were seen in one patient each. The sites of involvement
in decreasing order were: upper extremity in 32 (542%), lower extremity in 29 (492%), face
in 27 (458%) and trunk in 26 (441%). Twenty-three (39%) patients presented with a single
skin lesion and in these cases, the upper extremity was the commonest site of involvement in
nine (391%), followed by the face in eight (348%) and lower extremity in six (261%)
children. Two to five lesions were seen in 12 (203%) and more than five lesions or diffuse
infiltration in 22 (373%) patients. Thirty one (525%) patients were diagnosed as MB and 28
(475%) as PB disease. Thickened peripheral nerve trunks were present in 48 (814%)
children, of whom 21 (437%) had a single thickened nerve and 27 (563%) had more than
one

Figure 2. Single well-defined erythematous, oedematous, scaly infiltrated plaque on face; BT leprosy with type 1
reaction.
 Figure 3. Ill-defined, slightly erythematous to hypopigmented infiltrated plaque on face; BT leprosy.

thickened nerve. The most frequent nerve affected was ulnar, followed by the common
peroneal and radial cutaneous nerves.

SL IT S K IN SM E AR ( SS S) AN D H I S T O PA THO L OGI C AL FI
NDINGS

The SSS was positive in 17 (288%) children, of whom 12 had a bacillary index (BI) of 2
or higher. Pre-treatment morphological index (MI) in 12 of 59 (203%) children ranged
from 1% to 10%. Post- treatment MI became zero in 10 children, however, in two children
with an initial MI of 10% it was 5% after 1 year of MDT-MBR. The latter two children
had persistent nodules, infiltrated macules of LL and developed multiple episodes of ENL
even after 1 year of treatment. Both of them were given MDT-MBR for 24 months and
subsequently their MI became zero. Among SSS positive cases, there were seven LL cases,
six BL, two BT and one each of histoid and BB leprosy. Of the SSS negative patients, 38
were diagnosed as BT, two as pure neuritic and one each as tuberculoid and indeterminate
leprosy. Clinico-histopathological correlation was observed in 763% of all cases (Table 2).
Histopathology of single lesions was consistent with borderline tuberculoid in 14
(609%), indeterminate in eight (348%) and tuberculoid in one (43%) patient.
 Figure 4. Single hypopigmented, infiltrated plaque with sparse hair and satellite lesions on face; BT leprosy.

RE ACT I ON S A ND DI S A BI LI TI ES

Reactions were seen in 20 (339%) patients, of whom 14 (70%) developed Type 1, and six
(30%) manifested with Type 2 lepra reaction (Figures 5 & 6).

Table 2. Clinical and histopathological classification

Histo-pathological classification: Number (%)

Clinical Not
classification Number (%) BT BL LL TT Histoid specified

BT 40 (678) 30 (75) 2 (5) 8 (20)

LL 7 (119) 2 (286) 5 (714)
BL 6 (101) 5 (83) 1 (17)
PNL 2 (34) 2 (34) (in nerve biopsy)
BB 1 (17) 1 (17)
TT 1 (17) 1 (17)
Histoid 1 (17) 1 (17)
Indeterminate 1 (17) 1 (17)

BT: Borderline Tuberculoid, LL: Lepromatous: BL: Borderline Lepromatous, PNL: Pure neuritic leprosy, BB:
Mid-borderline, TT: Tuberculoid
Figure 5. Multiple tender, discrete to coalescent erythematous papules and nodules on trunk and proximal arms;
LL leprosy with type 2 reaction.

Neuritis was present in nine patients (153%) and a nerve abscess in one patient. Of those
who developed neuritis, seven patients had Type 1 lepra reaction and two had erythema
nodosum leprosum (ENL). The ulnar nerve was the most commonly affected nerve (8/9).
Oral prednisolone starting at 40 mg/day and tapered every 2 weeks was given for reactions.
Pentoxiphylline 1200 mg/day and clofazimine 100 mg twice a day were used in steroid
dependent cases (inability to taper steroids below 20 mg/day) with good control of ENL.
Surgical decompression of the nerve was carried out in the patient with a nerve abscess.
Twenty-four children (407%) had disabilities of hands and feet at the time of presentation.
WHO Grade 1 disability was seen in five (85%) and Grade 2 disability in 19 (322%)
children (Figure 7).

Figure 6. Oedema of prepuce and erythematous nodules on thighs; LL leprosy with type 2 reaction.
Figure 7. Grade 2 disability of hand including trophic ulcers, total claw hand, auto-amputation of little finger and
thumb and wasting of thenar and hypothenar muscles; LL leprosy.

Patients with disabilities of , 6 months duration were given oral prednisolone starting at
30 40 mg/day and gradually tapering every 4 weeks. Physiotherapy was advised for all
cases with motor weakness.

TR EAT M E N T O UT COM
E

On follow-up, 53 (898%) children completed the recommended schedule of MDT. Among

the defaulters, four had multibacillary and two had paucibacillary disease. Two cases of
paucibacillary and one of multibacillary disease relapsed between 2 to 3 years after
treatment completion. All of these relapsed as multibacillary disease in the form of new
patches and infiltrated plaques, activity in previously healed lesions and new onset sensory
and motor impairment. The BI became positive in PB patients and increased by 2 in MB
patients. Histology showed ill-defined granulomas composed of foamy macrophages with
sparse epithelioid cells and positive solid staining acid fast bacilli on modified Fite-Faraco
staining. All three were treated with MDT-MBR and showed improvement.

Discussion
1
The global prevalence of leprosy at the end of first quarter of 2013 was 189,018 cases.
According to the National Leprosy Eradication Programme (NLEP) report (March 2013),
the prevalence in India was 91,743 cases and there were 134,752 new cases at the end
2
of first quarter of 2013 with the child case rate of 107/100,000 population.
The proportion of child cases was more than 10% of new cases detected in 12 States/
2
Union territories of India. At our centre, we found the child proportion to be 481% during
7
the period 2001 2011. The average proportion of childhood cases was 771% (study
period
8
1992 2003) and 96% (study period 2000 2009) respectively in two studies from
Delhi (north India) while the figures from south India (study period June September
9 10
2007 and 1990 1995 respectively) were significantly higher (341% and 331%
respectively).
This may be due to the overall lower prevalence of disease or a lower proportion of migrants
from endemic states in Chandigarh, as compared to other states. This is also supported by
the fact that all states of south India have reported child proportion of . 10% in 2012
2
13.
However, the differences in incidence or prevalence could be the outcome of overall disease
control in some areas, a difference in case detection methods (primary surveys in schools or
hospital based studies) or lack of standard age criterion for the child category in different
studies (Table 3).
The percentage of affected children was highest (593%) in the age group of 11 14
8,11
years. A similar age related peak has been reported in earlier studies. The preponderance
of older children could be due to the long incubation period of leprosy and also to the
failure to identify and report in the early stages of the disease. In the present study, boys
outnumbered girls in the ratio of 39:1 which is in accordance with the previous
8,11,12
studies. This may be due to greater risk of exposure in males, or neglect of female
children in seeking medical treatment in some Indian communities.
The mean duration of symptoms exceeded one year in 64% of children in our study
which can be attributed to poor knowledge of leprosy among community, barriers in access
to health care or its utilization and inadequacy of services in a given area. This could also be
the reason for the high percentage of patients with disabilities at the time of diagnosis.
Previous studies on childhood leprosy have reported a mean duration of disease ranging
7,8,12
from less than 1 year to 16 years. As the prevalence of leprosy has declined, active
case detection strategies and the index of suspicion in a given case by health care
professional might be decreasing, leading to delay in diagnosis.
Overall, 254% children had a history of contact with a leprosy case, the majority (22%)
being household members. Parents were the potential source of infection (contact) in most
of the cases (667%), however their status (pauci or multibacillary) was generally not
available from the records. A positive contact history in childhood leprosy has been shown
to vary from
7,9 14
87% to 388% in various studies. In one of these studies, 95% of the contacts were
11
familial, with 65% being MB and 35% PB contacts. The risk of developing leprosy is four
times greater if there is contact in the neighbourhood and it increased to nine times if present
15
among the household members. The probability of transmitting leprosy to a child is
highest when there is a multibacillary case in the family and is also greater when the mother
is the index case. The risk from paucibacillary contact in the family is the same as with
15
multibacillary case in the neighbourhood. It is therefore important to take a complete
family history and examine all the members.
The commonest category in the spectrum was BT disease in 678% of children, followed
by LL in 119% and BL in 101% cases. Pure neuritic and indeterminate leprosy were seen in
34% and 17% patients respectively. The preponderance of BT cases is in concordance with
8,11 13
the previous epidemiological studies. Histoid leprosy was diagnosed in only 1 patient
12,13
and has been infrequently reported in childhood leprosy studies. Our study showed that
multiple and single lesions were present in 576% and 39% children respectively. While
11,16
some studies have reported a higher percentage of children with multiple lesions, others
8,12,17
have shown single lesions to be more common. The upper extremity (391%) followed
by the face (348%) were common sites for single skin lesions in our study, similar to a
16
previous study.
SSS positivity was seen in 288% children, which included all BL, LL cases, one case
each of BB and histoid and two cases of BT leprosy (downgrading). A BI greater than or
equal to 2 and MI positivity were seen in 203% of all cases. SSS positivity in childhood
 30
6

S.
Do
gr
Table 3. Comparison of clinico-epidemiological patterns of childhood leprosy in various studies from India a
et
al.
Kaur Sehgal Selvasekar Kumar Jain Grover Mahajan Rao Horo Singal Shetty Present
16 12 10 18 11 13 7 14 23 8 9
et al. et al. et al. et al. et al. et al. et al. et al. et al. et al. et al. study
(1991) (1993) (1999) (2000) (2002) (2005) (2006) (2009) (2010) (2011) (2013) (2013)

Child rate (%) 124 506 313 45 98 706 771 1143 15 96 341 481
Commonest age 10 14 8 14 10 14 11 14 , 14 11 15 11 15 11 14 11 14 11 14
group* (years)
Sex (M:F) 22:1 26:1 125:1 19:1 3:2 14:1 23:1 25:1 125:1 23:1 134:1 39:1
Contact (%) 197 87 298 388 219 29 18 43 145 33 254
Commonest BT (59) BT BT (605) BT (787) BT (663) BT (708) BT (73) BT (687) TT (437) BT (703) BT (581) BT (678)
clinical
form (%)
No. of lesions (%) Many (545) Single (596) Single (83) Many (634) Single (44) Many (625) Many (. 60) Single (529) Many (50) Many (576)
SSS positivity (%) 174 18 2 94 226 28 25 99 198 8 288
Nerve 666 608 70 523 70 814
thickening (%)
Classification (%) PB PB (783) PB (98) PB (83) PB (71) PB (63) PB (812) PB (67) MB (517) PB (735) MB (525)
Reactions (%) 74 31 41 297 146 23 624 46 186 0 339
Disabilities (%) 68 434 05 24 (G 2) 13 312 16 (G 2) 128 (G 2) 44 407
Treatment 80 j 2 898
completion (%)
Relapse (%) 164 116 51

*
Upper age limit varied from 14 to 19 years in different studies
307 S. Dogra et al. Childhood leprosy in North India 307
7 14
leprosy has been reported to vary from 2% to 28% in various studies. The slow decline
in MI from 10% to 5% at the end of 12 months of MDT- MBR in two patients may indicate
a poor response to rifampicin, requiring drug resistance studies in such cases. Even though
BT leprosy forms a majority of clinical diagnoses in children, the importance of SSS in
children cannot be overemphasized as it aids in the identification of multibacillary cases
and the institution of appropriate treatment. Monitoring of the SSS during and at the end of
treatment aids in identifying response or resistance to treatment in multibacillary cases and
as a reference for diagnosis of relapse if it occurs later.
Thickened nerves were present in about 81% cases, with the ulnar nerve most commonly
involved. Multiple nerves were thickened in 563% while single nerve involvement was seen
in 437% children. Similar to our figure, other studies in childhood leprosy have reported
a high frequency (70% and 60.8% respectively) of nerve involvement (ulnar nerve being
8,11
the commonest). A high percentage of nerve thickening predisposes to increased risk of
reactions, disabilities and consequent psychological burden in children.
We observed a slightly higher percentage of children with multibacillary disease. This is
in contrast to most previous studies, which showed paucibacillary disease to be more
7,9 13
common. However, a recent study from a tertiary care hospital in Delhi has also
8
reported MB leprosy to be more common than PB disease in children. Although the result
cannot be generalized to predict a trend, it does indicate a shift in the spectrum of childhood
leprosy, likely due to the high proportion of MB disease among the contacts of children.
However, this could also be due to the fact that it was a hospital based study. Community
based studies should be undertaken to ascertain this shift in scenario. A change in
classification system of leprosy based on the number of skin lesions and thickened nerves
may also explain the MB preponderance.
In our study, we observed clinico-histopathological correlation in 763% cases. BL cases
showed 83% correlation while it was 75% for BT and 714% for LL respectively. Both, the
8,14
high rate of 861% and the low rate of 375% for concordance have been reported.
Positive correlation was more likely to be seen in infiltrated lesions of BT or BL leprosy
compared to indeterminate cases, and non-specific features point towards impaired and
18
non-specific immune response in children. It has also been suggested that selection of the
site of biopsy plays an important role in the histopathological diagnosis and clinically
dissimilar lesions biopsied from the same patient can show different types of
19
histopathology. Skin biopsies are more likely to identify multibacillary cases compared to
smears as they cover a larger amount of tissue, including cutaneous nerve twigs, whose
20
bacillary load can be 1000 times higher than in inflammatory infiltrates. A single
hypopigmented patch on the face in children has a high risk of misdiagnosis, since there
are numerous causes of hypopigmented patches in children and biopsy is important to reach
a diagnosis in doubtful cases.
Lepra reactions were seen in 339% and neuritis in 153% of children. These figures are
8,12 14
significantly higher in comparison to previous studies. The high percentage of
multibacillary disease and nerve thickening in our cohort might have resulted in an increased
rate of reactions. However, few hospital based studies have also reported low to zero rate of
12,14,21
reactions in childhood leprosy. The high rate of neuritis emphasizes the importance of
a meticulous neurological examination at the time of diagnosis and thereafter at every visit.
Disabilities were present in 407% patients and were considerably higher than reported in
8,12 14,22
previous studies. The high burden of disability may be due to the increased
incidence of neuritis, particularly silent neuritis in multibacillary cases, multiple thickened
nerves and delay in seeking treatment. Early identification and treatment of neuritis is
important to
prevent irreversible sequelae in those at high risk of developing disabilities. These include
children with borderline disease, high bacillary index, multiple thickened nerves and a past
history of neuritis. A study on disabilities in children identified the following risk factors:
increasing age, delay in accessing health care, multiple skin lesions, multibacillary disease,
smear positivity, multiple nerve involvement, and reaction at the time of presentation. Nerve
thickening was most significant of all the factors increasing the risk of disabilities by 613
times. A majority of the disabilities involved the upper limbs and only 10% occurred in
22
lower limbs. Disabilities can lead to psychological disturbances both for the child and his
family. The high percentage of disabilities in the present study emphasises the need for
their prevention, early detection and management. The Enhanced Global Strategy for further
reducing the disease burden due to leprosy aims at reducing the rate of new cases with
Grade 2 disabilities worldwide by $ 35% by the end of 2015 compared with the baseline
at the end of 2010.
We observed 898% treatment completion rate and only six children defaulted. To reduce
the number of defaulters, we often gave 2 3 blister packs at one visit for patients from
distant places. However, it is necessary to reinforce strict treatment compliance to reduce
the incidence of drug resistance. Relapse was seen in 51% children compared to 116 %
and
8,10
164% reported in other studies. Two children with paucibacillary and one with
multibacillary disease relapsed as multibacillary disease within 3 years of treatment
completion. Irregular or inadequate therapy and a high baseline BI in MB cases might be
responsible for relapse. All three relapse cases were treated with MDT-MBR for another 1
year with good response. This emphasises the importance of long term follow-up for at least
4 5 years after completion of MDT-MBR for timely diagnosis and treatment of relapse.
Comparing the trends with two previous studies from the same institute, the present
study showed the child proportion rate to be 481% as against 124% in 1991(study period
1982
16 18
89) and 45% in 2000 (study period 1990 99). The peak age group of 11 14 years
and
16,18
male preponderance were comparable. The mean duration of disease was less than 1
16
year in the previous study in contrast to 185 months in this study. Percentage of contact
with a leprosy case was higher in present study (254%) compared to 197% reported
16
previously from same centre. In this study, BT leprosy was the commonest clinical
spectrum seen in
16,18
678%, as observed previously (59% and 787%). Multiple lesions (. 5) were present in
16
a majority of children both in the present and previous studies. A higher percentage
of children (814%) had peripheral nerve thickening in this study compared to 666% in
the
past16 (ulnar nerve commonest in both). SSS positivity increased markedly from 174% in
16
1991 to 288% in the present study. The proportion of MB cases was also higher in this
16
study compared to the previous study. Clinico-histopathological correlation was higher
18
in the present study (763%) compared to 606% in the previous study. Reactions and
16
disabilities showed remarkable rise from 74% and 68% respectively in 1991 to 339% and
407% respectively in the current study. The overall figures depict higher multibacillary load
and associated complications in the present scenario compared to the previous studies.
The limitations of this study were the retrospective analysis of the data and representation
of advanced referral cases evaluated in our tertiary centre, reflecting very little of the overall
scenario in the communities. There are scarce data about the hidden or undetected leprosy
cases in the community. But hospital based data are valuable and provide information
regarding the clinical, bacteriological and histopathological characteristics of child leprosy
cases present in the community.
Conclusion

Although the leprosy case load is gradually declining worldwide in the post-elimination era,
the proportion of childhood leprosy as evident in this study is a cause of concern for all stake
holders in the leprosy control program. This study highlights the presence of a higher
percentage of SSS positivity, multiple lesions and thickened nerves in children, thereby
pointing to proportionate increase in multibacillary disease in contrast to paucibacillary in
the recent past. The higher proportion of multibacillary disease in children suggests the
presence of potential contacts among family members of these cases and a shift in
epidemiological trends. This in turn reflects the continuing high burden of disease in the
post-elimination era. Hence, contact tracing particularly in household members should be
carried out.
The incidence of complications such as reactions and disabilities, considered less
common in children, has also alarmingly risen. A majority of patients presented late in
the course of disease (1 5 years) when they first developed symptoms of reaction,
thereby contributing to delayed diagnosis and increased rate of disabilities. If not
detected and treated early, childhood leprosy cases would serve as a persistent source of
infection in the community.
Although the treatment completion rate was satisfactory, the relapse rate was high. The
present scenario emphasises the need for continued efforts for better community awareness
in order to self-report and seek leprosy services at an early stage when active case detection
has been abandoned. There must be no complacency in leprosy control program in endemic
regions. Integration of leprosy services with primary health services should be strengthened
so that health workers are trained to suspect and diagnose leprosy at an early stage. They
must also establish close links with the referral centres for confirmation of diagnosis if
required, and management of reactions and disabilities.

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