Leprosy (Hansens disease)

By Dr M Adnan Rashid,
AP, Community Medicine,
AMC, Abbottabad

Introduction

Leprosy is a chronic infectious disease

caused by M. leprae
It affects mainly the peripheral nerves
and also affects the skin, muscles, the
eyes, bones, testes and internal organs
The disease manifests itself in two polar
forms namely
i. The lepromatous leprosy &
ii. Tuberculoid leprosy

Contd

Between these two polar types occur the

borderline
and
intermediate
forms
depending upon the host response to
infection

Contd

Leprosy is clinically characterized by one

or more of the following clinical features;
o Hypopigmented patches
o Partial or total loss of cutaneous sensation in
the affected areas (the earliest sensation to
be affected is usually light touch)
o Presence of thickened nerves &
o Presence of acid fast bacilli in the skin or
nasal smear

Contd
The signs of advanced disease are striking;
Presence of nodules or lumps especially in the skin of
the face and ears
Plantar ulcers
Loss of fingers or toes
Nasal depression
Foot drop
Claw toes and
Other deformities

History
Leprosy is probably the oldest disease
known to mankind
The word leper comes from the Greek
word meaning scaly
For a long time, disease was confused with
psoriasis, elephantiasis and pellagra
Modern day leprosy dates from 1873 when
Hansen of Norway discovered M. leprae

Contd

Leprosy was recognized in the ancient

civilizations of China, Egypt and India
The first known written mention of leprosy
is dated 600 BC
Throughout history, the afflicted have often
been ostracized by their communities and
families

Contd

For long years, there was no effective

remedy for leprosy
It seemed that the only way to handle the
patients was to isolate them for life in
special institutions
The introduction of sulphone drugs in the
treatment of leprosy in 1943 marked the
beginning of a new era the era of case
finding and domiciliary treatment

Key facts
Official figures show that almost 182 000
people, mainly in Asia and Africa, were
affected at the beginning of 2012, with
approximately
219 000
new
cases
reported during 2011
M. leprae multiplies very slowly and the
incubation period of the disease is about
five years. Symptoms can take as long as
20 years to appear

Contd

Leprosy is not highly infectious. It is

transmitted via droplets, from the nose
and mouth, during close and frequent
contacts with untreated cases
Untreated, leprosy can cause progressive
and permanent damage to the skin,
nerves, limbs and eyes

 Early diagnosis and treatment with

multidrug therapy (MDT) remain the key
elements in eliminating the disease as a
public health concern

Epidemiological determinants
AGENT FACTORS
Agent:
Leprosy is caused by M. leprae
They are acid-fast and occur in the human
host both intracellularly and extracellularly
They occur in clumps or bundles (called globi)
The bacterial load is highest in the
lepromatous cases

Contd

Source of infection:
It is generally agreed that multibacillary cases
are the most important source of infection in
the community
The inapparent infections are also an
important source of infection
Until recently, the man was considered to be
the only host & source of infection

Contd
There is now evidence that natural infections
with M. laprae are present in wild animals e.g.
armadillos,
mangabey
monkeys
and
chimpanzees
It is not yet known that if leprosy in wild
animals is a threat to public health

Contd
Portal of exit:
It is widely accepted that the nose is a major portal of
exit
Lepromatous cases harbor millions of M. laprae in
their nasal mucosa which are discharged when they
sneeze or blow the nose
The bacilli can also exit through ulcerated or broken
skin of bacteriologically positive cases of leprosy
They may also be discharged from the intact skin
also, probably through hair follicles

Contd

Infectivity:
Leprosy is highly infectious disease but of low
pathogenicity
It is claimed that an infectious patient can be
rendered non infectious by treatment with
dapsone for about 90 days or with rifampicin
for 3 weeks
Local application of rifampicin (drops or spray)
might destroy all the bacilli within 8 days

Contd

Attack rates:
Among household contacts of lepromatous
cases, a varying proportion 4.4% to 12% is
expected to show signs of leprosy within 5
years

Epidemiological determinants
HOST FACTORS
Age:
Leprosy is not particularly a disease of
children as was once believed
Infection can take place at any time
depending upon the opportunities for
exposure
In endemic areas, the disease is acquired
commonly during infancy and childhood

Contd

Sex:
Both the incidence and prevalence of leprosy
appear to be higher in males than in females
in most regions of the world
Sex difference is found least in children below
15 yrs, and more marked among adults

Contd

Immunity:
It is a well established fact that only a few
persons exposed to infection develop the
disease
A large proportion of early lesions that occur
in leprosy heal spontaneously
Subclinical infections are far more common
than was thought earlier

Contd

Genetic factors:
There is now evidence that HLA-linked genes
influence the type of immune response that
develops

Epidemiological determinants
ENVIRONMENTAL FACCTORS
The risk of transmission is predominantly
controlled by environmental factors
There is evidence that humidity favors the
survival of M. leprae in the environment
M. leprae can remain viable in dried nasal
secretions for at least 9 days & in moist soil at
room temperature for 46 days
Over crowding and lack of sanitation among
households are important in the spread

Mode of transmission
Droplet infection:
There is more and more evidence that leprosy
may be transmitted via aerosols containing M.
leprae (droplet infection)
With the realization of the importance of the
nose as a portal of exit, there has been
increased emphasis on the respiratory tract
as the portal of entry

Contd

Contact transmission:
Numerous studies show that leprosy may be
transmitted from person to person by close
contact between an infectious patient and a
healthy but susceptible person
This contact may be direct (skin to skin) or
indirect (e.g. contact with soil or fomites)

Contd

Other routes:
Bacilli may also be transmitted via breast milk
from lepromatous mothers, by insect vectors
or by tattooing needles

Incubation period
Leprosy has a long incubation period, an
average of 3-5 years or more for
lepromatous cases
The tuberculoid leprosy is thought to have
a shorter incubation period

Diagnosis
Diagnosis of leprosy is most commonly
based on the clinical signs and symptoms
These are easy to observe and elicit by
any health worker after a short period of
training
In practice, most often persons with such
complaints report on their own to the
health centre

Contd

Only in rare instances is there a need to

use laboratory and other investigations to
confirm a diagnosis of leprosy
In an endemic country or area, an
individual should be regarded as having
leprosy if he or she shows ONE of the
following cardinal signs

Contd

i.

Skin lesion consistent with leprosy and

with definite sensory loss, with or without
thickened nerves
ii. Positive skin smears

Skin lesions in Leprosy

Saddle nose deformity & arm

nodules in leprosy

Active, Neglected Nodulous

Lepromatous Leprosy Lesions on Face

Ulcerated foot & deformed hands

in leprosy

Eye complications in leprosy

Contd

The skin lesion can be single or multiple,

usually
less
pigmented
than
the
surrounding normal skin
Sometimes the lesion is reddish or
copper-coloured. A variety of skin lesions
may be seen but macules (flat), papules
(raised), or nodules are common
Sensory loss is a typical feature of leprosy

Contd
The skin lesion may show loss of sensation to
pin pick and/or light touch
Thickened nerves, mainly peripheral nerve
trunks constitute another feature of leprosy
A thickened nerve is often accompanied by other
signs as a result of damage to the nerve
These may be loss of sensation in the skin and
weakness of muscles supplied by the affected
nerve

Contd
In the absence of these signs, nerve thickening
by itself, without sensory loss and/or muscle
weakness is often not a reliable sign of leprosy
Positive skin smears: In a small proportion of
cases, rod-shaped, red-stained leprosy bacilli,
which are diagnostic of the disease, may be
seen in the smears taken from the affected skin
when examined under a microscope after
appropriate staining

Contd
A person presenting with skin lesions or with
symptoms suggestive of nerve damage, in
whom the cardinal signs are absent or doubtful
should be called a `suspect case' in the absence
of any immediately obvious alternate diagnosis
Such individuals should be told the basic facts of
leprosy and advised to return to the centre if
signs persist for more than six months or if at
any time worsening is noticed

Elimination of leprosy as a
public health problem
In 1991 WHO's governing body, the World
Health Assembly (WHA) passed a
resolution to eliminate leprosy by the year
2000
Elimination of leprosy is defined as a
prevalence rate of less than 1 case per
10 000 persons

Contd

The target was achieved on time and the

widespread use of MDT reduced the
disease burden dramatically.

Contd

Over the past 20 years, more than 14

million leprosy patients have been cured,
about 4 million since 2000
The prevalence rate of the disease has
dropped by 90% from 21.1 per 10 000
inhabitants to less than 1 per 10 000
inhabitants in 2000

Contd

Dramatic decrease in the global disease

burden: from 5.2 million in 1985 to
805 000 in 1995 to 753 000 at the end of
1999 to 181 941 cases at the end of 2011
Leprosy has been eliminated from 119
countries out of 122 countries where the
disease was considered as a public health
problem in 1985

Contd

So far, there has been no resistance to

antileprosy treatment when used as MDT
Efforts currently focus on eliminating
leprosy at a national level in the remaining
endemic countries and at a sub-national
level from the others

WHO response
The WHO Strategy for leprosy elimination
contains the following:
ensuring accessible and uninterrupted MDT
services available to all patients through
flexible and patient-friendly drug delivery
systems
ensuring the sustainability of MDT services by
integrating leprosy services into the general
health services and building the ability of
general health workers to treat leprosy

Contd
encouraging
self-reporting
and
early
treatment
by
promoting
community
awareness and changing the image of leprosy
monitoring the performance of MDT services,
the quality of patients care and the progress
being made towards elimination through
national disease surveillance systems

Contd
Sustained and committed efforts by the national
programmes along with the continued support
from national and international partners have led
to a decline in the global burden of leprosy
Increased empowerment of people affected by
the disease, together with their greater
involvement in services and community, will
bring us closer to a world without leprosy

Leprosy control
The following elements are considered as a minimum
requirement for all leprosy control programs;
Medical measures

Estimation of the problem

Early case detection
MDT
Surveillance
Immunoprophylaxis
Chemoprophylaxis
Deformities
Rehabilitation
Health education
others

Contd

Social support
Program management
Evaluation

3 main goals of leprosy control

The three main goals of leprosy control are;

i.

To interrupt transmission of the infection, thereby

reducing the incidence of the disease so that it no
longer constitutes a public health problem
ii. To treat patients in order to achieve their cure and
where possible complete rehabilitation
iii. To prevent the development of associated
deformities

Ultimate prevention is achieved by breaking

the chain of transmission

Thank You