Leprosy

Leprosy

1. LEPROSY PRESENTED BY: MIGOM PRIYANSH MODERATOR: DR.N.K.SAINI 1

2. Also known as Hansen’s disease Chronic infectious disease Characterized by lesions of the peripheral nerve, skin and mucus membrane of the URT(nasal mucosa ) Develops slowly from 6 months up to 40 yrs. 2

3. HISTORY Comes from the ancient Greek word ‘ lepra ’ Earliest record of leprosy like disease from Egypt (1550 BC) In India and China first records appeared in 600 BC Hippocrates discussed leprosy in 460 BC, Rome- 62 BC In India, leprosy was first described in the Sushruta Samhita and treatment with ‘chaulmoogra’ oil was known at that time, referred to as KUSHT 3 a disease that makes the skin scaly

4. 4 Robbins et al., DOI: 10.1371/journal.pone.0005669

5. 1873- Dr. Gerhard Henrik Armauer Hansen of Norway was the first person to identify the germ 1921- U.S. Public Health Service established the Gillis W. Long Hansen’s Disease Center in Carville, Louisiana, which became known as “Carville .” Till 1940s , leprosy doctors all over the world treated patients by injecting them with oil from the chaulmoogra nut 1941-Promin (miracle of Carville), a sulfone drug, was introduced 1950- Dapsone pills, pioneered by Dr. R.G. Cochrane at Carville, became the treatment of choice 1970- The first successful multi-drug treatment (MDT) regimen for leprosy was developed through drug trials on the island of Malta 1981- The WHO began recommending MDT https://web.stanford.edu/class/humbio103/ParaSites2005/Leprosy/history.htm 5

6. “Leprosy work is not merely medical relief; it is transforming frustration of life in to joy of dedication, personal ambition into selfless service” 6

7. PROBLEM STATUS 7

8. GLOBAL LEPROSY SITUATION (2014) Registered prevalence No. of new cases detected No. of new cases of MB No. of females among new cases No. of new cases among children No. of new cases with grade 2 disability No. of relapses Africa 19968 (11.3%) 18597 (8.7%) 14480 (11.17%) 6075 (7.5%) 1920 (10%) 2726 (19.3%) 228 (17.3%) Eastern Mediterranean 2212 (1.3%) 2342 (1%) 1823 (1.4%) 848 (1%) 142 (0.7%) 300 (2.1%) 31 (2.3%) Americas 29976 (17%) 33789 (15.8%) 22383 (17.3%) 15018 (18.6%) 2441 (17.4%) 2222 (15.7%) 120 (9.1%) South east Asian 119478 (68%) 154834 (72.4%) 87405 (67.4%) 57176 (70.9%) 13977 (74.1%) 8525 (60.4%) 788 (60%) Western pacific 3929 (2.2%) 4337 (2%) 3501 (2.7%) 1427 (1.7%) 381 (2%) 337 (2.3%) 145 (11%) Total 175554 (0.31/10,000) 213899 (3.78/100,000) 129592 (60%) 80544 (37%) 18861 (8.8%) 14110 (6.6%) 1312 8 Source: WER, WHO, SEPT. 2015

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10. 13 countries reported > 1000 cases during the reporting year 94% of all cases Bangladesh, Brazil, Congo, Ethiopia, India, Indonesia, Madagascar, Myanmar, Nepal, Nigeria, Philippines, Sri Lanka, United Republic of Tanzania 10

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13. NLEP PROGRESS REPORT 2011-12 2012-13 2013-14 2014-15 New cases 127295 1,34,752 1,26,913 1,25,785 Registered cases 83,041 83,687 86,417 88,833 MB cases 63,562 (49.93%) 67,268 (49.92%) 65,337 (51.48%) 66,436 (52.82%) Female 47,111 (37.01%) 50,828 (37.72%) 46,485 (36.91%) 46,379 (36.81%) Child cases 12,305 (9.67%) 1/lakh 13,387 (9.93%) 1.07/lakh 12,043 (9.49%) 0.95/lakh 11,365 (9.04%) 0.88/lakh Grade II deformity 3,865 (3.04%) 3.14/million 4,650 (3.45%) 3.72/million 5,256 (4.14%) 4.13/million 5,794 (4.61%) 4.48/million 13

14. TREND OF PREVALENCE RATE and ANNUAL NEW CASE DETECTION RATE IN INDIA 14

15. CLINICAL FEATURES 15

16. Mode of transmission Although human-to-human transmission is the primary source of infection, three other species can carry and (rarely) transfer M. leprae to humans: chimpanzees, mangabey monkeys, and nine-banded armadillos . Droplet infection ( Every 1 cc of nasal secretion contains 1- 2millions lepra bacilli ) Contact transmission Other routes 16

17. Signs and Symptoms Early signs and symptoms of leprosy are very subtle and occur slowly (usually over years). First symptoms : Numbness and loss of temperature sensation (cannot sense very hot or cold temperatures) As the disease progresses : The sensations of touch, then pain, and eventually deep pressure are decreased or lost. 17

18. Long-term developing sequence of events Relatively painless ulcers, skin lesions of hypopigmented macules (flat, pale areas of skin), and eye damage (dryness, reduced blinking) Late stage: large ulcerations, loss of digits, and facial disfigurement . (for example, hands, feet, face, and knees). 18

19. Classification & Clinical Presentation 19 1. RIDLEY AND JOPLING CLASSIFICATION

20. 20 2. WHO CLASSIFICATION

21. 3. INDIAN CLASSIFICATION Indeterminate type Tuberculoid type Borderline type Lepromatous type Pure neuritic type 21

22. Indeterminate Leprosy (IL) Usually single (multiple) macule / patches Hypopigmented or faintly erythematous Sensation normal but sometimes impaired The peripheral nerves normal Slit skin smear negative 22 Indeterminate leprosy : Hypopigmented patch, sensation normal, no palpable peripheral nerve and slit skin smear negative.

23. Tuberculoid Leprosy (TL) Usually single but may be few ( < 5) Hypopigmented /erythematous plaque Varying in size from few mm to several cm Well defined borders Sensation markedly impaired Enlarged peripheral nerve Slit skin smear negative 23 Tuberculoid leprosy: Two hypopigmented patches, hypoasthetic well defined borders, palpable peripheral nerve and SSS negative.

24. Borderline Leprosy (BT,BB,BL) Few / many asymmetrical patches. Partly well-defined borders. Sensory impairments range from slight to marked. Slit skin smear usually positive. P. nerves asymmetrically enlarged. 24

25. BT BB BL Lesion no. Few (<5) Some Many Lesion borders Well Less Roughly Sensory impairment Marked Moderate Slight Distribution of skin lesions Asymmetrical Asymmetrical Roughly symmetrical Peripheral nerves Asymmetrical Asymmetrical Less Asymmetrical Type of leprosy Multibacillary Multibacillary Multibacillary Slit skin smear - /1+ 2+/ 3+ 4+ Note: Sometimes patients may have BT/BB or BB/BL or BL/LL 25

26. Lepromatous Leprosy (LL) Very numerous ill defined lesions. (macules, patches, papules and nodules). Symmetrically distributed allover the body Loss of eyebrows and eyelashes. No sensory impairments in lesions . Peripheral nerves symmetrically enlarged. Slit skin smear always positive. 26 Leonine Face

27. Diagnosis of Leprosy Clinical Examination. Slit Skin Smear. Skin Biopsy. 27

28. 1.Clinical examination : Cardinal skin signs of leprosy 1. Hypopigmented or erythematous patch / plaque 2. Complete / partial loss of sensation 3. Thickening of peripheral nerves 28

29. 2.Slit Skin Smear Simple and valuable test It is needed for diagnosis and to monitor the progress of the treatment 29

30. Slit Skin Smear (Reporting the smear ) Ridley’s logarithmic scale (Bacteriological index) 0 – no bacilli in 100 fields 1+ : 1-10 bacilli in 100 fields 2+ : 1-10 bacilli in 10 fields 3+ : 1-10 bacilli in 1 field 4+ : 10-100 bacilli in 1 field 5+ : 100-1000 in 1 field 6+ : >1000 bacilli field ( globi ). 30

31. TT BT BB BL LL Skin Lesions No. of Bacilli Slit skin test Immunity Clinical spectrum of leprosy 31

32. LEPRA REACTION S udden appearance of signs of inflammation in the skin lesions or nerves or eyes of a leprosy person R edness, swelling and sometimes tenderness of the skin lesions. New skin lesions or symptoms suggestive of new nerve damage Muscle weakness in the hands or feet Crop of subcutaneous nodules 32

33. TYPES OF REACTIONS TYPE -I (REVERSAL) TYPE-II (ENL) 1. Delayed hypersensitivity 1. Antigen antibody reaction 2. Occurs in both MB and PB type of cases (Borderline group) i.e. unstable types like BT,BB,BL 2. Seen in MB cases (BL and LL types) 3. Skin lesions suddenly become reddish, swollen, warm, painful and tender. New lesions may appear. 3. Red, painful, tender subcutaneous nodules (deep), appear in groups, recurrent and subside within few days, better felt than seen 4. Nerves enlarged, tender and painful- neuritis 4. Nerves may be affected but not common 5. Other organs not affected 5. Other organs like eyes, kidneys and testis may be involved 6. General symptoms- not common 6. Fever, joint pain, red eyes with watering 33

34. SIGNS OF REVERSAL REACTION If any of the following sign is found, the reaction should be treated as severe: Loss of nerve function Pain or tenderness in one or more nerves Silent neuritis Marked swelling and redness in skin patches Skin lesion that remains ulcerated Marked oedema of the hands, feet or face 34

35. SIGNS OF ENL REACTION If any of the following signs is found, the reaction should be treated as severe: Pain or tenderness in one or more nerves, with or without loss of nerve function Ulceration of ENL nodules Pain or redness of the eyes, with or without loss of visual acquity Painful swelling of testis or of the fingers Marked arthritis or lymphadenitis ENL reactions are complex medical problems requiring careful management 35

36. TREATMENT OF REACTIONS Bed rest Rest to the affected nerves by analgesics and splinting Prednisolone- 1mg/kg/day, single morning dose after breakfast - taper dose by 10 mg fortnightly till 20 mg/day - thereafter taper by 5 mg/day Clofazimine - One capsule (100mg) TDS x 4 or more weeks - One capsule (100mg) BD x next 4-12 weeks, followed by - One capsule (100mg ) OD x next 4-12 weeks or more Thalidomide – 200 mg BD or 100 mg QID 36

37. RELAPSE R e-occurrence of the disease at any time after the completion of a full course of treatment Generally rare CRITERIA RELAPSE REACTION Time since completion of treatment Usually more than 3 years Usually less than 3 years Progression of signs and symptoms Slow Fast Site of skin lesions In new places Over old patches Pain, tenderness or swelling No Yes - skin and nerves Damage Occurs slowly Sudden onset General condition Not affected Fever, joints pain, red eyes with watering 37

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39. MILESTONES 1955 - National Leprosy Control Programme (NLCP) launched 1981 - MDT recommended by WHO as cure 1983 - National Leprosy Eradication Programme launched 2004 - Leprosy integrated with General Health Service (GHS) 2005 - Elimination of Leprosy at National Level 2006 - DPMR introduced as a component of NLEP 2012 - Special action plan for 209 high endemic districts in 16 States/UTs 39

40. BACKGROUND 1 ST PHASE - WHO funded, from 1993-94 and 2000 , prevalence rate reduced from 24/10,000 population in 1992 before starting 1st Phase project to 3.7/10,000 by March 2001 2 ND PHASE - started for a period of 3 years from 2001-02, successfully ended on 31st Dec. 2004 . Continued with GOI funds from Jan.2005 After global elimination, target was reset for remaining 14 countries to achieve elimination by Dec.2005 National health policy set the goal to <1/10,000 by 2005 40

41. OBJECTIVES Elimination of leprosy i.e. prevalence of less than 1 case per 10,000 population in all districts of the country Strengthen Disability Prevention & Medical Rehabilitation of persons affected by leprosy c . Reduction in the level of stigma associated with leprosy 41

42. STRATEGIES Decentralized integrated leprosy services Early detection & complete treatment House hold contact survey Early diagnosis & prompt MDT Involvement of ASHAs i Strengthening of Disability Prevention & Medical Rehabilitation (DPMR) services IEC activities Intensive monitoring and supervision 42

43. INDICATORS FOR MONITORING PROGRESS Number and rate of new cases detected per 1,00,000 population per year Rate of new cases with grade-2 disabilities per 1,00,000 population per year Treatment completion/cure rate 43

44. FOR ASSESSING QUALITY OF SERVICE Proportion of Defaulters Number of relapses reported during the year Proportion of new cases diagnosed correctly Proportion of cases with new disabilities 44

45. FOR EVALUATING CASE DETECTION Proportion of new cases presenting with Grade-2 disabilities Proportion of child cases among new cases Proportion of female cases among new cases Proportion of multibacillary cases among new cases 45

46. New case detection rate: N ew cases detected during April to March X 1,00,000 Population Treatment completion rate (TCR): The reporting year is the year during which the last of the cases under treatment in the related cohort group completes their treatment PB and MB cases treated PB male/female and MB male/female cases treated Rural / Urban areas PB TCR= No. of new PB cases who completed MDT within 9 months X 100 No. of new PB cases who started MDT in the year MB TCR= No. of new MB cases who completed MDT within 18 months X 100 No. of new MB cases who started MDT in the year 46

47. Disability proportion: No. of new cases with disability Grade I/II X 100 Total no. of new cases detected MB case proportion: No. of MB cases among newly detected cases X 100 Total no. of new cases detected Child proportion: No. of children <15 yrs among new detected cases X 100 Total no. of new cases detected 47

48. Programme Implementation Plan (PIP) for 12th Plan Period-TARGETS S.NO. INDICATORS BASELINE (2011-12) TARGETS (BY MARCH 2017) 1. Prevalence Rate (PR) < 1/10,000 543 Districts (84.6 %) 642 Districts (100 %) 2. Annual New Case Detection Rate (ANCDR) < 10/1,OO,OOO population 445 Districts (69.3 %) 642 Districts (100 %) 3. Cure Rate Multi Bacillary Leprosy (MB) 90.56 % >95 % 4. Cure Rate Pauci Bacillary Leprosy (PB) 95.28 % >97 % 5. Grade-II disability rate in percentage of New cases 3.04 % 35 % reduction 1.98 % 6. Stigma reduction Percentage reported 50 % reduction over the percentage reported by NSS 48

49. PROGRAMME COMPONENTS Case Detection and Management Disability Prevention and Medical Rehabilitation Information , Education and Communication (IEC) including Behaviour Change Communication (BCC) Human Resource and Capacity building Programme Management 49

50. TREATMENT GUIDELINES MULTI BACILLARY PAUCI BACILLARY ADULT CHILDREN ADULT CHILDREN RIFAMCPICIN 600 mg once a month 450 mg once a month 600 mg once a month 450 mg once a month CLOFAZIMINE 300 mg once a month 50mg daily 150 mg once a month 50 mg alternate days DAPSONE 100 mg daily 50 mg daily 100 mg daily 50 mg daily TOTAL DURATION 12 months 12 months 6 months 6 months For children under 10 years of age: Rifampicin: 10 mg/kg BW Clofazimine : 1 mg/kg BW daily and 6 mg/kg BW monthly Dapsone : 2 mg/kg BW daily 50

51. ADVERSE REACTIONS TO MDT Minor problems Drug Management Red urine Rifampicin Reassurance Brown discolouration of skin Clofazimine Counselling Gastrointestinal problems All three Give drugs with food Anaemia Dapsone Give iron and folic acid More serious problems Drug Management Itchy skin, rash, SJ syndrome Dapsone Stop the drugs and consider alternative regimen Allergy, urticarial Dapsone or Rifampicin Jaundice Rifampicin Shock, purpura , renal failure Rifampicin 51

52. DISABILITY PREVENTION AND MEDICAL REHABILITATION (DPMR) Aspects Nomenclature: Anaesthesia Impairment Deformity Disability Handicap De- habilitation Destitution 52

53. Important nerves involved in leprosy: Facial nerve Ulnar nerve Median nerve Radial nerve Lateral popliteal nerve Posterior tibial nerve 53

54. ASSESSMENT AND GRADING OF DISABILITY Assessment of sensory function of nerve trunk Assessment of the motor function of nerve (VMT) Grading is done as follows: S (strong) = able to perform the movement against full resistance W (weak) = able to perform the movement but not against full resistance P (paralysed) = not able to perform the movement at all 54

55. Grading of disability Examination of parts WHO disability grades Sensory testing (ST) VMT HANDS Sensation present S 1 Sensation absent S 2 Sensation absent W or P FEET Sensation present S 1 Sensation absent S 2 Sensation absent W or P EYES VISION LID GAP BLINKING Normal No lid gap Present 2 Cannot count fingers at 6 meters Present/red eye /corneal ulcer/opacity Absent 55

56. Grade ‘0’ – No disability Grade ‘1’ – Anaesthesia over palms and soles Grade ‘2’ – Deformity or visible disability Limitations: does not measure the worsening or improvement by disability prevention and medical rehabilitation EHF score - sum of all the individual disability grades for two eyes, two hands and two feet (0-12) 56

57. IMPLEMENTATION OF DPMR SERVICES AT PRIMARY LEVEL GOAL: Disability burden due to leprosy ids reduced OBJECTIVES: 1. To prevent disability in new leprosy cases 2. To prevent new disability or worsening of disability in under treatment cases and in the cases who have completed the treatment STRATEGIES: 1. Empowerment of community and patients 2. Strengthening of capacity of ASHA 3. Strengthening of sub-centre and sector PHC 4. Strengthening of block PHC 5. Simplification of information system 6. Provision of materials 57

58. ACTIVITIES AT PRIMARY LEVEL 1. Early detection of leprosy and its complications 2. Early referral of disabled cases 3. Diagnosis and treatment 4. DPMR services 5. Referral services 58

59. IMPLEMENTATION OF DPMR SERVICES AT SECONDARY LEVEL OBJECTIVES: 1. To prevent disability in new leprosy cases 2. To prevent new disability or worsening of disability in under treatment cases and in the cases who have completed the treatment STRATEGY: 1. Formation of Disrict Apex Group at District HQ Hospitals 2. Provision of skin smear examination faculty and physiotherapy unit 3. P rovision of RCS services 4. Availability of customized foot wears 59

60. ACTIVITIES AT SECONDARY LEVEL 1. Validation and Diagnosis 2. Treatment 3. DPMR Services 4. Laboratory Services 60

61. IMPLEMENTATION OF DPMR SERVICES AT TERTIARY LEVEL OBJECTIVES: 1. To provide DPMR services with provision of aids and appliances 2. To hold camps and workshops for clearing of backlog of cases in need of RCS and training of surgeons 3. To integrate DPMR/RCS services in to medical colleges, PMR institutes and District hospitals 61

62. STIGMA IN LEPROSY Social process, experienced or anticipated, characterised by exclusion, rejection, blame, or devaluation that results from experience, perception, or reasonable anticipation of an adverse social judgement about a person or group. TYPES: Felt stigma Enacted stigma Institutional stigma DETERMINANTS OF STIGMA: Lack of knowledge Attitude Fear Blame and shame 62

63. DISCRIMINATION : Treatment of an individual or group with partiality or prejudice, defined in terms of human rights and entitlements An act or behaviour Way of expressing, either on purpose or inadvertently, stigmatizing thoughts 63

64. INTERVENTION STRATEGIES TO REDUCE STIGMA Following steps may help in spreading awareness: Developing understandings and concepts based on scientific knowledge Preventing iatrogenic stigma Involving communities/societies 64

65. SUGGESTED LINE OF ACTION UNDER NLEP IEC activities Involve different groups Utilise health day to spread messages on BCC Media agencies During ‘Health Mela ’ organize care and concern camp Women mobilisation Non-discriminatory behaviour guidelines Empower people affected by leprosy 65

66. REHABILITATION All measures aimed at reducing the impact of disability for an individual, enabling him or her to achieve independence, social integration, a better quality of life and self actualization. COMMMUNITY BASED REHABILITATION (CBR): A strategy within general community development for the rehabilitation , equalization of opportunities and social inclusion of all people with disabilities. 66

67. COMPONENTS OF CBR Empowerment Prevention of cause of disability Provision of care facilities Creating a positive attitude towards people with disabilities Provision of functional rehabilitation services Creation of micro & macro income – generation opportunities Management/monitoring and evaluation of CBR projects 67

68. INTERNATIONAL FEDERATION OF ANTI-LEPROSY ASSOCIATIONS 68

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70. LEPROSY COMPLEXES IN DELHI TAHIRPUR COMPLEX 29 colonies, spread over 100 acres (DDA, S ocial welfare, MCD) Around 1500 patients, 4000-5000 including family members Biggest, 2 complexes: One HLTB (home for leprosy and TB affected patients)- -Dr. Anand Mohan One RCL (rehabilitation complex for leprosy patients) -Dr. Jairam S Nagar Rs.1800 paid to each member of the family PEERAGARHI PATEL NAGAR LAJPAT NAGAR R.K PURAM LAMPUR- new in Haryana, plan to shift 50% of the patients 70

71. Awareness and advocacy Healthcare Sustainable livelihoods Education and training Research 71 The Leprosy Mission Trust India healing.inclusion.dignity