Leprosy Management by Dr. Aryan

management of leprosy in detail

1. Leprosy Management

2. No of new cases diagnose >1000 (2015)

3. Priority countries at global level Based on absolute and relative burden Composite index: Prevalence Annual new case detection Annual new case detection rate proportion of children Proportion of G2D among new cases G2D rate per million

4. District wise Case load(2072/73) National average 90.00 White (districts) n=7 9.4% Green (districts) n=50 66.60% Red (districts) n=18 24.00% Highest PR Dhanusa=3.25 National Target (2016-20) Elimination in District level by 2018 (by the end of 2015, 57 districts have achieved elimination status)

5. Leprosy Control To interrupt the transmission of infection To treat patients in order to achieve cure and where ever possible complete rehabilitation To prevent development of associated deformities

6. Principles of Action: Focus on early case detection before visible deformity occur. (Special focus on children) Target detection among higher risk groups through conducting campaigns Develop national plans to ensure screening of all close contacts. Promote steps to move towards the use of shorter uniform MDT Incorporate specific interventions against stigma and discrimination due to leprosy

7. Management Five main principles of treatment: Stop the infection with chemotherapy. Treat reactions and reduce the risk of nerve damage. Educate the patient to cope with existing nerve damage, in particular anaesthesia . Treat the complications of nerve damage. Rehabilitate the patient socially and psychologically .

8. Vision, Mission, Goal 2016 - 2020

9. Strategic pillars: P illar 1: Stop transmission of leprosy & its complications P illar 2: Stop discrimination against leprosy and promote inclusion P illar 3: Strengthen enablers: government ownership, coordination, partnership and capacity building

10. Management Multidrug Chemotherapy Main objectives To interrupt the transmission of infection To ensure early detection and treatment of cases to prevent deformities To prevent drug resistance

11. Pauci or Multi Bacillary BI ( bacterilogical index/ not bacillary) in slit-skin smears if BI is not available, the number of skin lesions

12. Definitions Regular Treatment If he or she has received MDT for at least 2/3 rd of months in any interval of time Defaulter case Patient on MDT , who has not collected treatment for 12 consecutive months Relapsed Case Patient whose therapy has terminated, having successfully completed adequate drug therapy but subsequently develop signs and symptoms of leprosy

13. Defaulter Case Defaulter who returns to the health center for treatment and shows one or more of the following signs should be given a new course of MDT : Reddish and/or elevated skin lesions appearance of new skin lesions since last examination new nerve involvement since last examination Lepromatous nodules Signs of erythema nodosum leprosum (ENL) or reversal reaction

14. Management WHO recommended regimen for adults: Pauci -bacillary Multi-bacillary Definition 5 or < lesions > 5 lesions Duration of therapy 6 months (can be completed in 9 months) 12 months (can be completed in 18 months) Drugs Rifampicin, 600mg Supervised (monthly) Dapsone , 100mg Not Supervised (daily) Rifampicin, 600mg and Clofazimine , 300mg Dapsone , 100mg and Clofazimine , 50mg

15. Adult PB pack Adult MB pack

16. Child PB Pack Child MB Pack

17. Duration of Treatment & Benefits of BPs MB Leprosy: MB Blister packs for 12 months within 18 months Low BI: 12 months High BI (> 4+) : 18 months PB Leprosy: PB Blister packs for 6 months within 9 months

18. Management Unable or refusal to take Rifampicin PB Leprosy: 6 months regimen consisting of daily administration of following; 50 mg Clofazimine with 2 of the following drugs: 400 mg ofloxacin , 100 mg Minocycline OR 500mg Clarithromycin

19. Management Unable or refusal to take Rifampicin MB Leprosy Above regimen followed by daily administration of 50 mg Clofazimine with 100 mg Minocycline OR 400mg Ofloxacin

20. Management Unable or refusal to take Clofazimine Replaced by Ofloxacin 400 mg daily OR Minocycline 100 mg daily Unable or refusal to take Dapsone PB Leprosy Clofazimine 50 mg daily substituted for dapsone MB Leprosy No further medication required

21. Dapsone (DDS) Diamino diphenyl sulfone MoA : Inhibition of PABA incorporation into folic acid  inhibit folic acid synthesis Adverse Effects: Mild haemolytic anaemia Dose related toxicity G6PD deficiency more susceptible Dose > 50 mg/day produce haemolysis Gastric intolerance: Nausea, anorexia (in beginners) Cutaneous reaction: Allergic rashes, fixed drug eruption, hypermelanosis , photoxicity Hepatitis

22. Rifampicin Potent bactericidal for M. leprae MoA : Inhibits DNA dependent RNA polymerase synthesis Adverse Effect Hepatotoxicity Flu like syndromes Red color urine (Adequate counselling )

23. Clofazimine Phenazine derivative Leprostatic and anti inflammatory properties MoA Interfere with template function of DNA in M. leprae Disruption of mitochondrial electron transport chain

24. Clofazimine ADRs: Skin Reddish-black discoloration of skin Discoloration of hair, body secretion Dryness of skin and itching Acneform eruption Conjunctival pigmentation (cosmetic concern) GI symptom: Enteritis with intermittent loose stools, nausea, abdominal pain, anorexia and weight loss (when higher doses used to control lepra reaction )

25. Second Line Drugs Ethionamide Alternative to clofazimine Inhibition of mycolic acid synthesis ADRs: Anorexia, Nausea, Epigastric discomfort Moxifloxacin Bactericidal Alternative to rifampicin

26. Second Line Drugs Minocycline Highly lipophilic Relief of lepromatous symptoms ADRs: Vertigo, Grey pigmentation of skin lesion Clarithromycin Alternative to MDT regimen

27. Patient Education After 3 days of chemotherapy, they are not infectious and can lead a normal social life Gross deformities are not inevitable Anaesthetic hands or feet special care  to avoid and treat burns and other minor injuries Good footwear

28. Reconstructive surgeries:

29. Treatment of Other Complications

30. Leprosy Vaccines Several candidate vaccines have been investigated: BCG BCG + killed M. leprae . Killed M. leprae Indication Immunoprophylaxsis Immunochemotherapy : Highly bacillated patients

31. Rehabilitation Physical and mental restoration Social, psychological and vocational rehabilitation Community based rehabilitation strategy Equlization of oppurtunities Intersectoral Co-ordination

32. C oncern for social stigmas in leprosy

33. Dealing with Stigmas! achieving the acceptance of the leprosy patients in the community along with social status culturally acceptable in the absence of disease/ill health Spreading awareness Developing understandings & concepts based on scientific knowledge Preventing iatrogenic stigma Involving communities/societies (CBRs)

34. References: WHO Guidelines for Diagnosis, Prevention & Treatment of Leprosy, 2018 Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases, Neena Khanna, 5 th Edition Clinical Dermatology – Virendra Sehgal Uptodate.com

35. Thank You