LEPROSY

HOSPITAL OF LEPROSY Dr.RIVAI ABDULLAH PALEMBANG
Leprosy
www.searo.who.int/en/Section10/Section20/Section2293.htm

Cause
Leprosy is a chronic disease caused by a bacillus, Mycobacterium leprae (M. laprae).
M. leprae multiplies very slowly and the incubation period of the disease is considered to be about five years.

TRANSMISSION
Leprosy is transmitted by air through droplets from the nose and mouth, during close and frequent contacts with untreated cases.
Leprosy is one of the least infectious diseases, because:

Over 99% of the population has adequate natural immunity;
Over 85% of the clinical cases are non-infectious, and
An infectious case is rendered non-infectious within one week, most often after the very first dose of treatment.

SYMPTOMS
Leprosy mainly affects the skin and peripheral nerves.
If left untreated, it can lead to progressive and permanent damage of nerves, leading to loss of sensation and sweating in the extremities and paralysis of muscles in the hands, feet and face.
The disease is classified as paucibacillary (PB) or multibacillary (MB), depending on the bacillary load.
PB leprosy is a milder disease characterized by few (up to five) skin lesions (pale or reddish), whereas MB is associated with multiple (more than five) skin lesions, nodules, plaques, thickened dermis or skin infiltration.

HISTORY OF THE DISEASE
The first known written mention of leprosy is dated 600 BC.
Leprosy was recognized in the ancient civilizations of China, Egypt and India.
All countries of the South-East Asia Region were known to be endemic for leprosy.
Throughout history, the afflicted have often been ostracized by their communities and families. This situation has changed since leprosy is now completely curable and there is greater awareness about the disease.

HISTORY OF TREATMENT
The first breakthrough occurred in the 1940s with the development of the drug dapsone, which cured the disease. But the duration of the treatment of leprosy was many years, even a lifetime, making it difficult for patients to be regular in their treatment.
In the 1960s, M. leprae started to develop resistance to dapsone, the world’s only known anti-leprosy drug at that time.

TREATMENT TODAY
In 1981, a World Health Organization (WHO) Study Group recommended multi-drug therapy (MDT), a combination of three drugs.
MDT effectively kills the pathogen and cures the patient.
Treatment provided in the early stages averts disability.
With minimal training, leprosy can be easily diagnosed by clinical signs alone.

WHAT IS MDT
MDT comprises of three drugs, dapsone, rifampicin and clofazimine. Rifampicin and clofazimine were discovered in the early 1960s.
MDT is safe, effective and easily administered under field conditions.
MDT is available in convenient monthly calendar blister packs.
Since 1995, WHO has been providing free MDT for all patients in the world, initially through the drug fund provided by the Nippon Foundation and since 2000, through the MDT donation provided by Novartis and the Novartis Foundation for Sustainable Development.
Novartis has pledged free supply of MDT till 2010.

HIGH EFFECTIVENESS OF MULTIDRUG THERAPY
Transmission of leprosy is interrupted after the very first dose of MDT. In other words, patients are no longer infectious to others after being administered the first dose of the treatment regimen.
PB patients treated with MDT are cured within six months.
MB patients treated with MDT are cured within 12 months.
There are virtually no relapses, i.e. no recurrences of the disease after treatment is completed.
No resistance of the bacillus to MDT has been detected.
WHO estimates that early detection and treatment with MDT has prevented about four million people from becoming disabled.
MDT is very cost-effective as a health intervention, considering the economic and social losses averted.

THE ELIMINATION OF LEPROSY AS A PUBLIC HEALTH PROBLEM
In 1991 World Health Assembly passed a resolution to eliminate leprosy as a public health problem by the year 2000. Elimination of leprosy as a public health problem is defined as a prevalence rate of less than one case per 10,000 population.
Globally, the leprosy elimination goal was achieved in 2000.
The global disease burden reduced from 5.2 million in 1985 to 805,000 in 1995 to 753,000 at the end of 1999 to about 219,826 cases at the end of 2005.
The South-East Asia Region, including India, achieved the elimination goal in December 2005.
The Regional prevalence rate steadily declined from 4.6/10,000 population in 1996 to 0.82/10,000 population as of July 2006.
The Regional new case detection also declined from a peak of 47.8/100,000 in 1998 to 11.9/100,000 as of March 2006.
Between 1985 and 2005, more than 15 million leprosy cases were cured globally. Of these, about 12.8 million were from the SEA Region, of which India accounted for about 11.8 million.
The SEA Region has made substantial contribution to the achievement of leprosy elimination globally.

CURRENT LEPROSY SITUATION
At the beginning of 2006, about 219,826 cases were under MDT globally and the prevalence rate was about 0.2 per 10,000 population.
Globally, 296,499 new cases of leprosy were detected during 2005.
The top 10 countries in new case detection in 2005 are India, Brazil, Indonesia, DR Congo, Bangladesh, Nepal, Mozambique, Nigeria, Ethiopia and Tanzania. Together, they constitute about 96% of the 2005 global new case detection.
The SEA Region contributed to about 69% of the 2005 global new case detection.
Six countries (small countries with <1 million population excluded), Brazil, DR Congo, Madagascar, Mozambique, Nepal and Tanzania are yet to achieve the elimination goal.
In the SEA Region, two countries, Nepal and Timor-Leste (population of Timor-Leste is less than 1 million) are yet to achieve elimination.
As of December 2005, the PR in Nepal was 1.81/10,000 and Timor-Leste 1.89/10,000 population. These countries are expected to achieve elimination in 2006 or 2007.

REMAINING CHALLENGES
Achieving elimination in the remaining countries and sustaining elimination in the countries that have achieved the goal at the national level.
Sustaining political commitment and ensuring adequate resources in order to sustain elimination at national level, and progress towards further reducing the burden of leprosy.
Strengthening integration of leprosy services into the general health system through capacity building and skill development, in order to ensure and sustain quality leprosy services, including diagnosis and treatment and prevention/care of disabilities.
Ensuring a wider coverage of leprosy services, especially in currently under-served population groups such as remote rural areas, urban slums, migrant labour.
Increasing and sustaining community awareness through sustained advocacy and IEC activities to promote voluntary case detection and decrease the stigma.
Minimizing/preventing operational factors, such as:

Setting case detection targets and basing performance appraisal on target achievement
Over-diagnosis and re-registration of cases due to:

Non-adherence to WHO-recommended case definitions
Active search and surveys repeatedly targeting the same population groups
Repeated leprosy elimination campaigns in the same areas
Lack of “Quality” and “Accuracy” of diagnosis

Multiple registration
Wrong classification - PB cases recorded as MB (more frequent than vice-versa)
Delayed treatment completion due to:

Irregularity
Drug shortage at peripheral level

Delayed release from treatment
Over-treatment
Non-existent cases
Job insecurity among vertical staff leading to large number of suspect/doubtful cases being recorded as leprosy cases

Preventing discrimination and displacement of leprosy affected and ensuring community based rehabilitation and integration of cured/disabled leprosy persons into the community.
Streamlining the MDT supply and stock management at all levels, considering the low endemic situation.
Strengthening existing partnerships and identifying new partners to support leprosy activities.

THE STRATEGY FOR LEPROSY ELIMINATION
Sustain leprosy services and activities in all endemic countries.
Use annual new case detection and cure rates as the main indicator to monitor progress.
Ensure high-quality diagnosis, case management, recording and reporting in all endemic countries.
Strengthen routine and referral services.
Discontinue the campaign approach, since they are not cost-effective any more and lead to over-detection.
Develop tools and procedures that are home/community-based, integrated and locally appropriate for the prevention of disabilities/impairments and for the provision of rehabilitation services.
Promote operational research in order to improve implementation of a sustainable strategy.
Encourage supportive working arrangements with partners at all levels.

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