EPIDEMIOLOGY OF

LEPROSY
Vd. Jay Joshi
Swasthavrutta evam Yoga Department
LEPROSY
 Leprosy – Hansen’s disease

 Chronic infectious disease

 Caused by – Mycobacterium leprae

 It affects mainly the PERIPHERAL NERVES

 May also affect –

- Skin, Eyes, Bones, Tests and internal organ

- Mucosa of the upper airway

DR. JAY JOSHI
 The disease manifests itself in 2 polar forms
1. LEPROMATOUS LEPROSY
2. TUBERCULOID LEPROSY

- Lying these 2 polar types occur the borderline (BL) and

intermediate (IL) forms depending on the
- Host response to Infecction

DR. JAY JOSHI

 Cardinal features -
1 or more of the following –
- Hypopigmented patches

- Partial or a total loss of cutaneous sensation in the affected

area

- Present of thickened nerves

- Presence of Acid Fast Bacilli in the skin of nasal smears

DR. JAY JOSHI

 The signs of advanced disease are striking –
- Presence of nodules or lumps especially in the skin of the face and
ears

- Plantar ulcers

- Loss of fingers or toes

- Nasal depression

- Foot drop

- Claw toes and other deformities

DR. JAY JOSHI
AGENT FACTOR
 MYCOBACTERIUM LEPRAE

 Acid Fast bacilli

 Occurs in both as Intra-cellular and Extra-cellular bacilli

 Strict human pathogens

 Can not be cultivated in-vitro

 They occur characteristically in Clumps OR Bundles called GLOBI

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Source of Infection
 Multibacillary cases

(Lepromatous and Borderline Lepromatous cases)

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Portal of Exit
 The NOSE is the major portal of exit

 Lepromatous cases harbour MILLIONS of M.leprae in their

NASAL MUCOSA which are discharged when they are
SNEEZE or BLOW the nose

 The bacilli can also exit through ULCERATED or BROKEN

SKIN of bacteriologically POSITIVE CASES of leprosy

DR. JAY JOSHI

INFECTIVITY
 Highly infective disease

 An infectious patient can be rendered non-infectious by

treatment with DAPSONE for abut 90 days or with
RIFAMPISIN for 3 weeks

 Local application of RIFAMPISIN (drops/spray) might destroy

all the bacteria within 8 days

DR. JAY JOSHI

ATTACK RATE
 Despite the treatment,
ALL THE CASES HAVE BEEN INFECTIOUS FOR LONG
PERIODS

DR. JAY JOSHI

HOST FACTOR
 An individual can get infected any time depending upon the
opportunities for exposure

 In endemic area, commonly during CHILDHOOD

 Generally rise to peak between – 10 to 20 years of age and

then fall

DR. JAY JOSHI

 GENDER :
- Higher in MALES than FEMALES
[MALES > FEMALES]

 MIGRATION :
- Mostly a rural problem
- Today, Due to migration – Both in Rural and Urban areas

DR. JAY JOSHI

 IMMUNITY
 Only a few persons exposed to infection develop the disease

 A large proportion of early lesions that occur in leprosy heal spontaneously

 Such abortive self healing lesions suggests - immunity acquired through such
lesions

 A certain degree of immunity is probable – through infection with other related

mycobacterium

 Cell-mediated immunity (CMI) is responsible for resistance to infection

with M. leprae

 In lepromatous leprae – there is complete breakdown of CMI

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DR. JAY JOSHI
ENVIRONMENTAL FACTORS

 The risk of transmission is predominantly controlled by

environmental factors

 Humidity favors the survival of M. leprae in the environment

 M. leprae can remain viable in the dried nasal secretion for at

least 9 days and in moist soil at room temperature for 46 days

 Overcrowding and lack of ventilation within the household

favors transmission
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MODE OF TRANSMISSION
 Transmission occurs by –
1. DROPLET infection

2. CONTACT transmission

3. OTHER routes

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1. DROPLET INFECTION
 NOSE is the most important portal of exit

 M.leprae could survive outside the human host for SEVERAL

HOURS or DAYS

 Large number of organism found in – DRIED NASAL

DISCHARGED in to the environment as DROPLETS

DR. JAY JOSHI

2. CONTACT TRANSMISSION
 PERSON TO PERSON

 Close contacts to an infectious patient

 This contact may be DIRECT / INDIRECT (i.e. soil, fomites,

clothes, linen)

DR. JAY JOSHI

3. OTHER ROUTES
 By INSECT VECTOR

 By TATTOOING NEEDLES

- But not important transmision route as previous

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 INCUBATION PERIOD
 Has a LONG incubation period

 An average of 3 to 5 years OR
even more for Lepromatous Leprosy

 Tuberculoid leprosy is thought to have a SHORTER incubation period

 Symptoms can take as long as 20 YEARS to appear

 Sometimes, prefer the “latent period” to incubation period because

of the LONG DURATION of the incubation period
DR. JAY JOSHI
 CLASSIFICATION
 Classified based on • Classified based on skin smear result
- Clinical - Paucibacillary Leprosy (PB)
- Multibacillary Leprosy (MB)
- Bacteriological
- Borderline Leprosy – between the 2
- Immunological
- Histological status → Differ in treatment regimen

DR. JAY JOSHI

PAUCIBALLARY MAULTIBALLARY
LEPROSY LEPROSY

 1 to 5 skin lesion  More than 5 skin lesion

 Asymmetrical distribution  Symmetrical distribution

 Definite loss of sensation  Loss of sensation may or may

 BI<2 at all sites in the initial not be present

skin smear  BI>/= 2 at any sites in the

initial skin smear

DR. JAY JOSHI

Types
INDIAN CLASSIFICATION MARDID CLASSIFICATION

INDETERMINATE INDETERMINATE

TUBERCULOID TUBERCULOID, FLAT-RAISED

BORDERLINE BORDERLINE

LEPROMATOUS LEPROMATOUS

PURE NEURITIC TYPE (NO SKIN LESION)

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INDETERMINATE
 Those early cases with
- One or two vague hypo-pigmented macules

- Definite sensory impairment

The lesions are bacteriologically

NEGATIVE

DR. JAY JOSHI

TUBERCULOID
 Those cases with
- 1 or 2 well defined lesions
- May be flat or raised
- Hypopigmented OR erythromatous
- Anesthetic

The lesions are bacteriologically NEGATIVE

DR. JAY JOSHI

BORDERLINE
 Those cases with –
- 4 or more lesions
- May flat or raised
- Well or ill defined
- Hypopigmented OR Erythromatous

- Sensory impairment or loss

The bacteriological POSITIVITY of these lesions is VARIABLE

- Without treatment, usually progresses to LEPROMATOUS type

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DR. JAY JOSHI
LEPROMATOUS
 Those cases with –
- Diffuse infiltrates or numerous lesions
- Flat or raised
- Poorly defined
- Shiny
- Smooth
- Symmetrically distributed

- Little or no loss of sensation

- Nerves are not thickened

- Loss of eyebrows –then spreads to→ eyelashes, trunk

- However scalp hair remains

The lesions are bacteriologically POSITIVE

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DR. JAY JOSHI
PURE NEURITIC
 Those case with –
- Nerve involvement
- Not have any lesion in skin

The cases are bacteriologically

NEGATIVE

DR. JAY JOSHI

CLINICAL FEATURES
 SKIN :
- Variable lesions
- Macules, papules, nodules
- Single / multiple
- Hypopigmented – sometimes reddish

- Sensory loss typically (Anaesthesia/Hypothesia)

 NERVES :
- Thickened
- Loss of sensation
- Muscle weakness
DR. JAY JOSHI
 Signs of advance diseases :
- Lumps or nodules in the skin of the
FACE and EAR

- Plantar ulcers

- Loss of fingers or toes

- Nasal depression

- Foot drop and claw toes

- Other deformities
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DR. JAY JOSHI
DIAGNOSIS
 Based on

1. CLINICAL EXAMINATION

2. BACTERIOLOGICAL EXAMINATION

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CLINICAL EXAMINATION
 Diagnosable on the basis of proper clinical examination alone,
called as – CASE TAKING

 Follows a ser pattern, as below :

1) INTEROGATION
2) PHYSICAL EXAMINATION

DR. JAY JOSHI

 1) INTEROGATION :
- Collection of biodata of the patient
[i.e. Name, Age, gender, occupation, place of residence]

- Family history of Leprosy

- H/O contact with leprosy cases

- Previous history of treatment for leprosy, if any

- Presenting complaint or symptom

DR. JAY JOSHI

 PHYSICAL EXAMINATION :
2)
- A thorough INSPECTION of the body surface – SKIN
- In good natural light
- For the presence of suggestive evidence of leprosy
- PALPATION
- Involved peripheral and cutaneous nerve
- For the presence of thickening and / or tenderness
- They are
- Ulnar nerve near the median epicondyle
- Dorsal branch of the radial nerve

- Testing for LOSS OF SENSATION for heat, cold, pain and light, touch in the
skin PATCHES

- PARESIS OR PARALYSIS OF THE MUSCLES of the hands and feet,

leading to the disabilities or deformities
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 Clinical symptoms

 Slit-skin smears : Ziehl Neelson staining

 Skin biopsy

 Nerve biopsy

 Lepromin test

DR. JAY JOSHI

2) BACTERIOLOGICAL EXAMINATION
 Done by –
1) SKIN SMEARS

2) NASAL SMEARS

3) NASAL SCRAPING

DR. JAY JOSHI

 1) SKIN SMEARS :

- Material form the skin

- Obtain form an active lesion
- Also from the ear lobe by the “SLIT & SCRAPE METHOD”

DR. JAY JOSHI

 2) NASAL SMEARS OR BLOW :
- Nasal spray can be best prepared from the EARLY MORNING
mucus material

- The patient is asked to blow his nose into a clean dry sheet

- Nose blowing smears are used for assessing the patient’s infectivity

- In untreated patients of Lepromatous leprosy, nose blow smears

may show a HIGHER % of solid –staining bacilli than skin smears

DR. JAY JOSHI

 3) NASAL SCRAPING :

 An alternative is to use a MUCOSAL SCRAPPER

 After going in 4.5 cm, the blade is rotated towards the

SEPTUM and scraped a few times and withdrawn

 Nasal scraping are not recommended as a routine

DR. JAY JOSHI

  FOOT PAD CULTURE :
 To inoculate the material into the FOOT PADS OF MICE an
demonstrate its multiplication

 The test is more sensitive than skin and nasal smears

DR. JAY JOSHI

Test for Detecting CMI
 LEPROMIN TEST :
- LEPROMIN TEST is not a diagnostic test

- Useful tool in evaluating the immune status

- Performed by INJECTING
- LEPROMIN
- 0.1 ml
- Intra-dermally – inner aspect of the forearm

- As a routine, the reaction is read at 48 hours and 21 days

DR. JAY JOSHI
 2 types of reaction happen
i. EARLY REACTION :
- Known as – Fernandez reaction

- Inflammatory response develops within 24-48 hours and 21 days

- Evidenced by redness

- If red area > 10 mm, the test is considered POSITIVE

- Indicates person has been previously sensitized by exposure to and

infection by the leprosy bacilli

- Similar to MONTOUX test for TB

DR. JAY JOSHI

ii. LATE REACTION
- Classical Mistuda reaction

- Develops late, become apparent in 7-10 days following the

injection

- Reaching its maximum in 3-4 weeks

- The test is read at 21 days

- At the end of 21 days

- A nodule > 5 mm in diameter at the site of inoculation
- The reaction is said to be POSITIVE

DR. JAY JOSHI

WHAT IS NOT LEPROSY !!
 Skin PATCHES which
- Have normal feeling
- Present form birth
- Cause itching
- Are white, black, dark red or silver colored
- Show scalling
- Appear and disappear periodically
- Spread quickly

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 Signs of damage to hands / feet / face without loss of sensation

- Due to other reasons like injury, accidents, burns, birth defects

- Due to other diseases like arthritis

- Due to other conditions causing paralysis

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 LEPROSY CONTROL

 Can be achieved through

1. ESTIMATION OF THE PROBLEM

6. CHEMO-PROPHYLAXIS
2. CASE DETECTION
7. DEFORMITIES
3. MULTIDRUG THERAPY
8. REHABILITATION
4. SURVEILLANCE
9. HEALTH EDUCATION
5. IMMUNO-PROPHYLAXIS
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MULTI-DRUG THERAPY

 Following drugs are used in the

management of the LEPROSY

A) RIFAMPISCIN E) QUINOLONES
B) DAPSONE F) MINOCYCLINE
C) CLOFAZIMINE G) CLARITHROMYCIN
D) ETHIONAMIDE AND
PROTIONAMIDE

DR. JAY JOSHI

CHEMOTHERAPY FOR ADULTS
 Rifampicin – 600 mg
once - monthly, given under
supervision  Clofamizine – 300 mg
once – monthly, under supervision
 Dapsone – 100 mg - 50 mg, daily
daily, self administered self administered

when clofazimine is un-acceptable

- Ethionamide - 250 to 750 mg
Daily, self administered
DR. JAY JOSHI
 For PAUCIBACILLARY leprosy

- RIFAMPICIN - 600 mg
- Once – month, under supervision

- Dapsone - 100 mg (1-2mg/kg body weight)

- Daily, self administered

DR. JAY JOSHI

REGIMEN OF CHEMOTHERAPY - By WHO

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CHEMOTHERAPY FOR CHILDREN
(10 to 14 years)
- Rifampisin – 450 mg
- Once – month, under supervison
- Dapsone 50 mg
- Daily, self administered
- Clofazimine – 150 mg
- Once – month, under supervision
- 50 mg, every OTHER day

DR. JAY JOSHI

 PAUCIBACILLARY LEPROSY :
- Rifampicin – 450 mg
- Once – month, under supervision
- Dapsone – 50 mg
- Daily, self administered

→ Children under age of 10 years

- Should receive appropriately reduced dosed of the above drugs

DR. JAY JOSHI

Duration of Treatment
 The treatment duration varies according to the type of disease

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PREVENTION
 NO SINGLE VACCINE, confers complete immunity in all
individually

 Report to local health authority

 Isolation – no restrictions in employment or attendance at school

are indicated

 Quarantine – not applicable

 Immunization of contacts – not recommended

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 Investigation of contacts and source of infection

 Specific treatment : MRT

 Any interruption of treatment schedule is serious

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ELIMINATION STRATEGY
 Providing MDT to all communities

 Braking the chain of transmission by intensive case detection

and prompt treatment

 Improving quality of patient care, including disability prevention

and management

 Ensuring regularity and completion of treatment

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 Encouraging and ensuring
community participation

 Providing rehabilitation to
the needy patients

 Organising health education

to patients, their families and
community

DR. JAY JOSHI

DR. JAY JOSHI
REHABILITATION
 Used for
- Reducing the impact for an individual,
- enabling him/her to achieve independence,
- social integration
- a better quality of life
- self actualization

DR. JAY JOSHI

IMPORTANT POINTS
 MDT is not contraindicated in patients with HIV infection

 MDT is safe during pregnancy

 Drugs are excreted in breast milk but no reports of adverse

reaction except for mild discoloration of infants skin by
clofazimine

 Leprosy is exacerbated during pregnancy, it is important that

MDT is continued
DR. JAY JOSHI