leprosy

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“LEPROSY”:

“ LEPROSY” Presented By – Dr. Gaurav J. Desai Resident Doctor, Community Medicine Dept., SBKS MI & RC, Piparia, Vadodara, Gujarat, India E-mail- dr_gauravdesai@yahoo.co.in

Slide 2:

“Anti Leprosy Day -30th January” Global Leprosy Situation Leprosy has been eliminated from the “ world” [1] BUT………..

Slide 3:

“65 % new global leprosy cases from India” Times of I ndia Kounteya Sinha , Aug 6, 2011 “India accounts for 55% of worldwide leprosy cases” Times of I ndia Saturday , September 3, 2011 “Leprosy in India only eliminated on paper” one world south asia , 29 March 2011 “Leprosy in India down but not out”: Azad September 02, 2011 “WHO warns leprosy spreading in India”

Content :

Content Introduction History Current Situation Epidemiology Classification Diagnosis Leprosy Control Disability Leprosy Reaction Differential diagnosis References

Leprosy :

Leprosy Leprosy is a chronic, infectious, slow-developing disease. Affecting mainly the peripheral nerves and the skin . Cardinal Features are….. Hypopigmented patches Loss of sensation (partial or total) Presence of thickened nerve Presence of acid fast bacilli in skin or nasal smear [2]

History :

History For a long time, leprosy was thought to be a hereditary disease, a curse, or a punishment from God In 1873 : Dr. Armauer Hansen of Norway was the first person to identify the germ that causes leprosy under a microscope. early 20th century: Until the late 1940s, doctors all over the world treated leprosy patients by injecting them with oil from the chaulmoogra nut . 1941 : Promin , a sulfone drug, was introduced as a treatment for leprosy . [3]

Slide 7:

“Leprosy work is not merely medical relief , It is transforming frustration of life in to joy of dedication, personal ambition into selfless service …….” -- MAHATMA GANDHI [3]

:

Current Situation [1] [4]

Slide 9:

Data of 2010-11 India No. of new cases 1.27 lakh ANCDR / 1 lakh population 10.48 Prevalence 0.83 lakh PR / 10,000 population 0.69 MB cases 48.6 % PB cases 51.4% Female cases 36.2 % Child cases 9.83 % Visible Deformity 3.1 % ST 14.3 % SC 18.7 %

:

3 States / UTs viz. Bihar, Chhattisgarh and Dadra & Nagar Haveli has remained with PR more than 1 per 10,000 population. These 3 states/UTs with 10.7 % of country’s population, Contributed 20.1% of country’s recorded caseload and…. 22.2 % of the country’s new cases detected during the year 2010-11. 32 States/ UTs had already achieved the level of elimination. New cases are increase in 11 state in 2010-11.

:

“Gujarat is model state in leprosy elimination. It has achieved a great success by effective planning and actions. All other should follow Gujarat ……..” -- Dr . A.P.J.ABDUL KALAM [3]

Treatment Completion Rate (TCR) for the reporting year 2009-10 :

Treatment Completion Rate (TCR) for the reporting year 2009-10 PB MB 94.55 % 89.87% Male Female 91.90% 93.01% Rural Urban 93.86% 85.7% Total 92.96%

Epidemiology :

Epidemiology Agent Factor Agent:- Mycobacterium Leprae Source of Infection:- All active case of leprosy Undetected cases Wild animal [ ?....] Portal of Exit:- During Sneeze or Blow the Nose [2]

Epidemiology cont…. Host Factor :

Epidemiology cont …. Host Factor 95% population naturally immune to leprosy in India. Age Distribution: 10-20 years, acquired infection commonly during childhood but can occur at any Age. Gender wise distribution: Male > Female Migration – Leprosy is a Mostly rural problem because of migration in urban area also.

Epidemiology cont…. Mode of Transmission:

Epidemiology cont …. Mode of Transmission Droplet Infection Contact Transmission Other Routes like… Insect vectors Tattooing needles Incubation Period:- 3-5 years….

Environmental Factor:

Environmental Factor Poverty Overcrowding Personal Hygiene Poor Housing lack of Education

Classification :

Classification Indian Ridley – Jopling Indeterminate type Tuberculoid ( TT ) Tuberculoid type Borderline Tuberculoid ( BL ) Borderline type Borderline ( BB ) Lepromatous type Borderline Lapromatous ( BL ) Pure Neuritic type Lapromatous ( LL )

Diagnosis :

Diagnosis Clinical Examination Bacteriological Examination Bacterial Index Morphological Index Foot – PAD culture Histamine test Biopsy Immunological test

Slide 30:

[5]

Clinical Examination :

Clinical Examination H /o taking Examination of Skin Test the feeling in the skin patches Test Nerves Test four muscle on each side Check the vision Check for leprosy reaction Check for complication of leprosy [6]

:

PB MB Skin lesion 1-5 in no. Asymmetrical Definite loss of sensation 5 in no. Towards symmetrical Loss of sensation ( may or may not be ) Nerve lesion Only 1 nerve involved 2 or more nerve involved

Slide 39:

Neural Leprosy

Leprosy Control :

Leprosy Control Medical Measures : - Estimation of problem Health Education Early case detection MDT Surveillance Immunoprophylaxis Chemoprophylaxis Treatment of Deformities Rehabilitation Social Support :- Programme Management :- Evaluation :- [2] [6]

National Leprosy Eradication Programme “Vision” :

National Leprosy Eradication Programme “Vision” “ The Attainment of Leprosy Free Status for the People of India” [4]

MDT (Multi Drug Therapy ):

MDT (Multi Drug Therapy ) It includes…. Rifampicin --- highly bactericidal drug Clofazimine Bacteriostatic Drugs Dapsone Before giving MDT…… Not given in Jaundice, Anemia In TB with leprosy cases, Rifampicin given accordingly TB therapy. In Allergic to sulpha drug cases, avoid Dapsone drug…. [5][6]

:

MB ADULT TREATMENT

:

Day 1 Supervised Monthly treatment Rifampicin 600mg Clofazimine 300mg Depsone 100mg Day 2-28 Daily : Clofazimine 50mg Daily : Depsone 100mg Once a month: Day 1 – 2 capsules of Rifampicin (300 mg X 2) – 3 capsules of Clofazimine (100mg X 3) – 1 tablet of Dapsone (100 mg) Once a day: Days 2–28 – 1 capsule of Clofazimine (50 mg) – 1 tablet of Dapsone (100 mg) Full course: 12 blister packs

Each blister pack contains treatment for 4 weeks.:

Each blister pack contains treatment for 4 weeks .

MB Child (10-14 years) Treatment :

MB Child (10-14 years) Treatment

:

Day 1 Supervised Monthly treatment Rifampicin 450mg Clofazimine 150mg Depsone 50mg Day 2-28 Alternate Day : Clofazimine 50mg Daily : Depsone 50mg Once a month: Day 1 – 2 capsules of Rifampicin (300 mg+150 mg) – 3 capsules of Clofazimine (50 mg X 3) – 1 tablet of Dapsone (50 mg) Once a day: Days 2–28 – 1 capsule of Clofazimine every alternate day (50 mg) – 1 tablet of Dapsone (50 mg) Full course: 12 blister packs

PB adult treatment :

PB adult treatment

:

Day 1 Rifampicin 600mg Dapsone 100mg Day 2-28 Daily : Dapsone 100mg Once a month: Day 1 – 2 capsules of Rifampicin (300 mg X 2) – 1 tablet of Dapsone (100 mg) Once a day: Days 2–28 – 1 tablet of Dapsone (100 mg) Full course: 6 blister packs

Pb child ( 10-14 years ) treatment:

Pb child ( 10-14 years ) treatment

:

Day 1 Rifampicin 450mg Dapsone 50mg Day 2-28 Daily: Dapsone 50mg daily Once a month: Day 1 – 2 capsules of Rifampicin (300 mg+150 mg) – 1 tablet of Dapsone (50 mg) Once a day: Days 2–28 – 1 tablet of Dapsone (50 mg) Full course: 6 blister packs For children younger than 10, the dose must be adjusted according to body weight.

Slide 55:

Before Treatment After Treatment

ASHA :

ASHA ASHA Gujarat (2010-11) [2][4] Total No. 28633 Trained No. 25314 Leprosy cases detected by ASHA 834 / 7309 No. cases completed treatment with ASHA supervision 400 Incentive On detection of case :- 100 ` On completion of treatment : - For per PB case – 200 ` For per MB case – 400 `

Surveillance :

Surveillance For PB cases – At least once in a year for a minimum up to “2” years after completion of treatment. For MB cases - A t least once in a year for a minimum up to “5” years after completion of treatment . [2]

ImmunoProphylaxis :

ImmunoProphylaxis BCG vaccine can provide protection against clinical leprosy. Efficacy varying from 0 to 80%. [2] Future……? BCG vaccine and other killed vaccine Better result of MDT…..

Disability :

Disability

Slide 60:

Disability Primary Secondary Bacterial Invasion Nerve damage Result of neglected case of Primary D isability Lagophthalmos Claw hand Foot drop Wrist drop Claw toes Non-healing planter ulcer Contracture [3]

Disability Grading :

Disability Grading WHO Grade 0 1 2 Eyes N Corneal reflex weak Reduced vision, lagophthalmos Hands N Loss of the feeling in the palm Visible damage to the hand, such as wound, claw hands, or loss of tissue Feet N Loss of feeling in the sole of foot Visible damage to the foot, such as wound, foot drop , or loss of tissue [6]

:

India Gujarat Relapse cases 632 0 Cases develop new disability 327 0 Disability develop after MDT 193 0 Cases provided with “ Footwear” 48543 10897 Cases provided with “self care kit” 41259 2479 [4]

Reaction in leprosy:

Reaction in leprosy Occurrence of leprosy reaction does not mean….. MDT drug reaction or MDT drug are not being effective MDT drug should not stopped during reaction…. Reactions are the part of natural course of disease which occurs frequently and damaging in untreated cases …. Treatment with leprosy significantly reduce the frequency and severity of reaction. [2][3]

Slide 65:

Type – 1 Reaction Upgrading or reversal Type – 2 Reaction Lapromatous or ENL

Differential Diagnosis :

Differential Diagnosis WHO has advised “Greater emphasis should be placed on, the specificity of diagnosis and it is already becoming important that, every new case detected be thoroughly investigated for correctness of diagnosis of the disease and possible identification of index case(s ). ” [5]

Slide 67:

Post-inflammatory hypochromia Birth Mark Contact dermatitis Scar Tissue

Slide 68:

Seborrhoeic dermatitis Tinea versicolor Tinea carcinata

Slide 69:

Lichen planus P soriasis V itiligo Tinea corporis

Slide 70:

Discoid lupus erythematosus Neurofibromatosis Lupus vulgaris (skin TB) Sarcoidosis

Slide 71:

Granuloma multiforme. Dermal leishmaniasis Lymphoma Kaposi’s sarcoma Pellagra

:

Sensation also lost in….. DM Carpal Tunnel Syndrome (CTS) Polyarthritis Nodosa Systemic Lupus Erythromatous HIV

References :

References http://www.who.int/lep/en K.park : epidemiology of communicable diseases, leprosy (20 th edition) Epidemiology of leprosy ppt : D r M uhammadirfan H. M omin , http://www.authersream.com http ://www.nlep.nic.in http://www.ilep.org.uk J.kishor’s : national health programs of india , chapter-13 (9 th edition)