Leprosy II

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Leprosy : 

Leprosy Daisy Dharmaraj , ACS medical college Ref:http://www.who.int/lep/situation/LEPPRATEJAN2009.pdf Park and Park LEPROSY – HANSEN’S Disease Part Two

Diagnosis : 

Diagnosis Clinical examination Case taking /Interrogation Physical examination Bacteriological examination Skin smear- active lesion, and ear lobe Nasal smears or blows Nasal scraping

Bacterial Indexnumber of bacilli in oil immersion fields (OIF) in an average microscopeHelp in monitoring : 

Bacterial Indexnumber of bacilli in oil immersion fields (OIF) in an average microscopeHelp in monitoring Bacterial Index= total of indices / number of sites examined Total number of + in 7 sites -4 skin lesions, 1 nasal swab, both ear lobes Pauci bacillary 2 Multibacillary>2

Morphological index : 

Morphological index It is the “Percentage of solid staining organisms in a stained smear” Uniform staining/ parallel sides. rounded end Length 5 times as width

Solid -fragmented- granular percentage : 

Solid -fragmented- granular percentage Indicator of patient's response o treatment during the first few months-- 200 pink stained free standing bacilli have to be counted Total of Mis for all sites / number of sites+ average MI for the body. Solid rods: Uniform staining of entire organism/ parallel sides, rounded end length 5 times the width - Viable Solid -fragmented- granular are given separately Better indicator of response

Foot pad culture : 

Foot pad culture Inoculate material into foot pads of mice Demonstrate its multiplication 10 times more sensitive than slit skin smears- 6-9 mths Macrophage culture: 3-4 wks Helpful to detect drug resistance Evaluate potency of anti leprosy drugs Viability of baciili during treatment

Histamine test : 

Histamine test Detecting at an early stage peripheral nerve damage due to leprosy Inject 0.1 ml of 1;1000 soln of histamine phosphate or chlorhydrate in hypo pig paches or anaesthetic patches flare response is lost Indeterminate leprosy

Slide 8: 

Biopsy Of skin Of nerve Immunological tests For detecting cell mediated immunity Tests for humoral antibodies

CMI Tests : Lepromin Test : 

CMI Tests : Lepromin Test Lepromin is a suspension of killed M leprae obtained from infected human or armadillo tissue. Mitsuda / Dharmendra Inject Lepromin O.1 ml inner aspect of forearm . Following intradermal inoculation, Read linke for PPD early (48 h, Fernandez) reactions and late (3-4 wk, Mitsuda) reactions may be seen.10 mm mild 15-20 mod >20 strong The Mitsuda reaction, a granulomatous response to the antigen, is more consistent. 3-4 weeks.Patients with TT or BT leprosy have str positive (>10 mm) responses, PATIENTS WITH L L DISEASE DO NOT RESPOND. The test is not useful in the diagnosis of leprosy because most of the population in both areas of endemic and nonendemic disease are Mitsuda positive. The lepromin test is a guide to the cell-mediated immunity of the individual.

CMI tests… : 

lymphocyte transformation test (LTT) and lymphocyte migration inhibition test (LMIT). Response decreases steadily in the progression from subpolar TT to subpolar LL leprosy CMI tests…

Tests for humoral response to M.lepraeSerologic tests : 

Tests for humoral response to M.lepraeSerologic tests fluorescent antibody absorption test (FLA-ABS), radioimmunoassay (RIA), enzyme-linked immunosorbent assay (ELISA), passive hemagglutination assay (PHA), serum antibody competition test (SACT), and particle agglutination assays (PAA). Important serologic tests are FLA-ABS test and PGL-1 ELISA, which have been simplified further as dot ELISA and dipstick ELISA. Serologic responses persist for considerable time after subsidence of disease and are not useful in assessing disease activity.

Leprosy ControlMedical measures : 

Leprosy ControlMedical measures Estimation of problem Early case detection Multi drug therapy Surveillance Immuno prophylaxis Chemo prophylaxis Deformities health education

Leprosy control ( contd) : 

Leprosy control ( contd) Social support Program management Evaluation GOALS To interrupt transmission reduce incidence To treat patients.. cure.. rehab To prevent formation of associated deformities

Estimation of the problem : 

Estimation of the problem Epidemiological survey Random sample surveys Prevalence among all school age children x 4 = average prevalence in the community

II.Early case detection : 

II.Early case detection Aim: identify and register all cases Involve primary health care workers Active community participation Methods Contact survey- household if 1 per 1000 Group survey..school/slum/military if prevalence is10 or more per 1000 :Mass surveys House to house Records; standardised:. Use WHO format Iceberg disease

III Multi Drug therapy- MDT : 

III Multi Drug therapy- MDT Mainstay of control Drug resistance leprosy due to monotherapy Relapse of disease Therefore MDT. Shorter treatment Objectives: To interrupt transmission by sterilizing infectious patients as rapidly as possible by bactericidal drugs To ensure early detection and treatment of cases to prevent deformities To prevent drug resistance

Definitions : 

Definitions Case of leprosy- person showing clinical signs with or without bacteriological confirmation, and who has not completed MDT Pauci bacillary: A person with 1-5 skin lesions and/or only 1 nerve involvement Multi bacillary ; A person having 6 or more skin lesions and /or more than1 nerve involvement Adequate treatment: completion of regimen of multi drug therapy – 6 mthly doses within 9 mths for paucibacillary and 12 mthly doses within 18 mths for multi bacillary

contd : 

contd Regular treatment: Received MDT for at least 2/3rd of the months in any interval of time Newly diagnosed case- Diagnosed as a leprosy case and who has not taken MDT in the past Defaulter case: A leprosy patient on MDT who has not collected treatment for 12 consecutive months Relapsed case: successfully completed an adequate course of MDT and who subsequently develops new signs and symptoms of the disease, within during the surveillance period or thereafter.

Principles of treatment : 

Principles of treatment Stop the infection with chemotherapy Treat reactions Educate the patient about leprosy Prevent disability Support patient socially and psychologically

Drugs : 

Drugs

WHO Recommended regimensAdultsmonthly / daily / both : 

WHO Recommended regimensAdultsmonthly / daily / both Multi bacillary: Rifampicin-600mg mthly under supervision x 12 mths DDS 100 mg OD x 12 mths CLF 300 mg mthly supervised and 50 mg OD- for 12 mths Pauci bacillary Rifampicin-600mg mthly x 6 mths supervised DDS 100 mg OD x 6 mths

WHO Recommended regimensChildren : 

WHO Recommended regimensChildren Multi bacillary: Rifampicin-450mg mthly under supervision x 12 mths DDS 50 mg OD x 12 mths CLF 150 mg mthly supervised and 50 mg alt days for 12 mths Pauci bacillary Rifampicin-450mg x 6 mths supervised DDS 50 mg OD x 6 mths

Defaulters : 

Defaulters Not registered as new cases Start a new course if she has red raised lesion/ new skin lesion/ new nerve involvement/ lepra nodules/ ENL or reversal reaction Drugs Shd be continued in pregnancy Can be given to HIV positive persons Tb, anemia

Lepra reaction : 

Lepra reaction Immunologically mediated episodes. Involve nerves. Can cause deformities if not treated Reversal – Type 1 Delayed Hypersensitivity reaction CMI. Usually in borderline BT BL BB cases. Erythema nodosum leprosum- Type II (mild/severe) Immune complex deposition. BL and LL patients Nodules, neuritis,High fever, ulcers and pustular, involve other organs-eye, testis, lymph node joints More with mono therapy than MDT Treat with Prednisolone 12 weeks only. CLF

Slide 26: 

Surveillance To detect long term success and detect relapse Pauci bacillary: Once an year x 2 yrs Multi bacillary : Once an year x 5 yrs Immuno prophylaxis BCG vaccine – varying results 23-30-80%

Candidate vaccine : 

Candidate vaccine Under Trial…. Category 1- based on M.leprae :killed/ killed + BCG; aceto acetylated M.leprae Category 2 – based on cultivable M.leprae BCG, BCG+ M.leprae; killed ICRC bacillus Venezuelan Indian – ICRC 1958/ 79 cancer research institute mumbai M waccae- National institute of Immunology Delhi

Chemo prophylaxis : 

Chemo prophylaxis DDS : 1-4 mg/kg for child contacts protects 35-53% Given 3 yrs or till index case becomes bact Neg. ICRC – effective for 8 yrs Acdapsone : Inj once in 10 wks long term or short term 7 mths Rifampicin ??

Deformities : 

Deformities Cause: Disease process- eye brows, facial Paralysis of muscles due to nerve damage-lag ophth, claw hand, foot drop Injuries infection of hands and feet- mutilation, corneal ulcer

Plantar ulcer : 

Plantar ulcer

Claw hands : 

Claw hands

Slide 32: 

Prevent these by lots of care … Preventive rehabilitation Health education- patient / family / public Treat by prosthesis/ surgery Protect people at risk Social support

Key Messages : 

Key Messages Hypopigmented patch with loss of sensation could be leprosy Like any disease Leprosy is caused by germs Leprosy is non hereditary and is a curse 80% do not spread to others It is completely curable Early detection and sustained treatment Become non infectious soon after treatment is commenced Need kindness and empathy Free treatment Not a poor man’s disease Community support s essential for eradication

Operational indicators : 

Operational indicators Relapse rate Case detection ratio Proportion of children ,14 yrs Proportion of multibacillary cases on regular treatment during one year Incidence rate Prevalence rate

Slide 35: 

17 states have achieved Leprosy elimination 7 more are nearing this Female 34.77% Child proportion is 13.77% Multi bacillary 39.3% Visible deformities 1.44%

Evaluation : 

Evaluation Operational indicators: case finding, treatment, relapse = managerial Epidemiological Incidence/ prevalence

Anti leprosy activities in India : 

Anti leprosy activities in India Leprosy mission Hindu kush Nivaran Sangh Gandhi memorial Sevagram German leprosy Relief association Damien Foundation Danish JALMA central institute in Agra Central leprosy teaching and research institute Chenglepet

Leprosy control or eradication The Final push: 2000 to 2005”. : 

Leprosy control or eradication The Final push: 2000 to 2005”. The target date was shifted to 2005. The final push strategy included (1) the integration of leprosy services into general health services to improve access to treatment; (2) capacity building to enable general healthcare staff to diagnose and treat leprosy; (3) improved logistics to ensure the provision of adequate stocks of MDT at health centres.

Katmandu recommendation” : 

Katmandu recommendation” GOI has changed the course of leprosy control work at all levels. (1) stop all new case detection, (2) all new cases detected to be registered and given MDT only after validation by authorities in each area, (3) delete names of the patients from the registers as they receive the last pulse, and (4) do not register single lesion leprosy cases for now. These recommendations were strictly implemented and thus India achieved the goal of elimination of leprosy by the end 2005 at the country level.

THE END : 

THE END

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