LEPROSY

By: NANCY YADAV

BAMS 3RD YEAR
Guided By: Dr.SHILPA
(Dept.of SWASTHVRITTA)
 CONTENTS
 INTRODUCTION
 HISTORY OF DISEASE
 PREVALENCE OF DISEASE
 EPIDEMIOLOGICAL DETERMINANTS
a. AGENT FACTORS
b. HOST FACTORS
c. ENVIRONMENT FACTORS
d. MODE OF TRANSMISSION
e. INCUBATION PERIOD
 CLASSIFICATION
 DIAGNOSIS
 LEPROSY CONTROL
 ANTI LEPROSY ACTIVITIES IN INDIA
 INTRODUCTION
 Chronic granulomatous infectious disease
 Caused by Mycobacterium leprae.
 Mainly involves the peripheral subcutaneous
nerves and skin
 Other organs may involve :
 Mucosa of mouth
 Upper respiratory tract
 Eyes
 Bones and Muscles,etc.
 CARDINAL
FEATURES
a. Hypo pigmented patches
b. Partial or total loss of cutaneous sensation in the affected
areas (the earliest sensation to be affected is usually light
touch)
c. Thickening and enlargement of nerves
d. Demonstration of M.leprae (AF bacilli) from the cutaneous lesions.

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.
CARDINAL SIGNS OF LEPROSY
 HISTORY OF LEPROSY

 One of the Oldest and most dreaded disease known to mankind

 Earliest description from India in 600BC
 Described as kushta roga in sushruta samhita.Kushta derived
from ‘kushnati’(sanskrit),means eating away.
 Word leper comes from Greek word means “ Scaly”
 In 1873,M.leprae was discovered by Gerhard Henrik ARMAUER
HANSEN Of Norway. Hence referred to as HANSEN’s DISEASE.
 PREVALENCE OF LEPROSY WORLDWIDE 🌍
 There were 127558 new leprosy cases detected globally in 2020, according to official figures from 139
countries from the 6 WHO Regions. This includes 8 629 children below 15 years. The new case detection
rate among child population was recorded at 4.4 per million child population.
 Among the new cases 7 198 new cases were detected with grade2 disabilities (G2D) and the new G2D
rate was recorded at 0.9 per million population
 At the end of the year 2020, the prevalence was 129 389 cases on treatment and prevalence rate
corresponds to 16.7 per million population.
 The COVID 19 pandemic has disrupted programme implementation and a reduction in new case
detection by 37% in 2020 compared with 2019
 In 2020, the countries with the highest number of new diagnoses were India,
Brazil, and Indonesia.
 India is the top country by leprosy cases in the world.
 As of 2020, leprosy cases in India was 65,147 that accounts for 51.09% of the world's
leprosy cases. The top 5 countries (others are Brazil, Indonesia, Democratic Republic of the
Congo, and Bangladesh) account for 78.88% of it. The world's total leprosy cases was
estimated at 127,506 in 2020.
LEPROSY IN
INDIA
Leprosy is widely prevalent in India.
In 1981 : 57.6 cases per 10,000 population

India has officially eliminated leprosy in

2005, reducing its prevalence rate to 0.72
per 10,000 people at national level. But
the country now hosts 66% of all leprosy
patients in the world.
 Leprosy is endemic in several states and union territories
of India, with the annual case detection rate of 4.56 per
10 000 population.
 The prevalence rate of leprosy is 0.4 per 10,000
population in the country.
 Of the new cases detected during 2020-2021, 58.1%
were multibacillary, 39% were women, 5.8% were children
less than 14 years of age, and 2.41% had visible
deformities.
 The rate of visible deformities was 1.1 per million
population.
Various leprosy endemicity
maps from 1981 to 2020, showing
the prevalence of leprosy at
different points of time, which
evidently show that the burden of
leprosy is shrinking in India.
EPIDEMIOLOGICAL DETERMINANTS
 EPIDEMIOLOGICAL DETERMINANTS

Agent: MYCOBACTERIUM LEPRAE

 Gram +ve ,Acid fast , rod shaped bacillus

 Occurs characteristically in clumps or bundles,’globi’.

 Affinity for Schwann cells and cells of R-E system.

 M.leprae grows best in cooler tissues(the skin peripheral nerves, upper respiratory tract ,
anterior chamber of eyes etc ) , sparing warmer areas of skin (the axilla, groin, scalp etc ).

 Cannot be cultivated on artificial medium or tissue culture .

 M.LEPRAE antigen: phenolic glycolipid (PGL)

 EPIDEMIOLOGICAL DETERMINANTS

Reservoir of infection

 Main reservoir : human being

 Animal reservoirs
a. 9 Banded armadillos
b. Chimpanzees
c. Mangabey monkeys
d. African green monkeys
 EPIDEMIOLOGICAL DETERMINANTS

Portal of exit

 Major portal of exit : nasal mucosa

 LL(lepromatous leprosy) cases harbor millions of M.leprae

in their nasal mucosa discharged when they sneeze or blow

nose

 Ulcerated or broken skin of bacteriologically positive cases

 EPIDEMIOLOGICAL DETERMINANTS
Infectivity
 Highly infectious disease but of low pathogenicity.
• Not all the cases of leprosy are infectious. Those cases,
who are shedding bacilli either from the nose and throat or
from the ulcerative, cutaneous lesions are infectious to others.
- Again, all those who are exposed to infectious case, do not develop
disease
- Generally, 95 to 97 percent of human beings are not susceptible to
leprosy.
- Only 3 to 5 percent are susceptible to leprosy.
- Among the susceptibles 80 to 85 percent patients get self-healing.
- Only remaining 15 to 20 percent develop the disease.
 EPIDEMIOLOGICAL DETERMINANTS
Host factors
 AGE
a) affects all age groups from early infancy to very old age
b) but incidence generally rises to a peak between 20 to 30 years of age.
c) Youngest age reported in south India is 2 and half months
 SEX
Leprosy is twice as common among males than among females .
However, the incidence is equal in both the sexes among children.

 MIGRATION

 PREVALENCE POOL
Constant flux resulting from inflow and outflow.
inflow due to : new cases, relapse if cured cases, immigration of cases
outflow due to : death , inactivation of cases .

 IMMUNITY
Cell mediated immunity (CMI) is responsible for resistance to infection with M.leprae.
In lepromatous leprosy , there is complete breakdown of CMI.
 EPIDEMIOLOGICAL DETERMINANTS

Environmental factors

 High Humidity favor survival of M.leprae in environment.

 M. leprae remain viable in dried nasal mucosa for about 8 to
10 days
 Minimum moist soil at room temperature for 46 days
 Overcrowding and lack of ventilation within households
favors transmission of leprosy.
 EPIDEMIOLOGICAL DETERMINANTS
Mode of transmission
A. DROPLET INFECTION
via aerosols containing bacteria

B. CONTACT TRANSMISSION
may be direct or indirect

C. OTHER ROUTES
insect vectors e.g.., mosquito, bedbugs
tattooing needles

 Key point : breast feeding and transplacental infection do not

occur.
 EPIDEMIOLOGICAL DETERMINANTS

Incubation period

Long incubation period

On maximum side it is 40 years or more
 average : 5-7 years
Fail to recognize early symptom
 Classification of leprosy

 Indian classification : clinicobacteriological

 Madrid classification: clinicobacteriological

 Ridley
Jopling classification :
immunohistological
 Classification
by WHO Study Group on
Chemotherapy of leprosy :
clinicobacteriological
Classification of leprosy
 Ridley – Jopling 1966
(research purposes)

 Most widely accepted

 Divided leprosy cases according to their
position on an immunohistological scale.
 It can be used only when full research
facilities are available.
a) Tuberculoid (TT)
b) Borderline Tuberculoid (BT)
c) Borderline Borderline (BB)
d) Borderline Lepromatous(BL)
e) Lepromatous (LL)
Tuberculoid (TT)—well-defined, Borderline (BB)—classical ‘punched-out’
hypopigmented lesion with dry surface and lesions of borderline leprosy; central
moderately raised granular margins; ‘immune’ areas are anesthetic
completely anesthetic
Borderline tuberculoid (BT)— Borderline lepromatous (BL)—numerous
multiple, sharply-demarcated, and widespread
scaly reddish-brown plaques; borderline type plaques, annular lesions,
these subsiding lesions are only papules and macules; center of
partially anesthetic. large lesions show some loss of sensation
(arrow head)
 Indian Classification
 Indeterminate type  Pure neuritic type
 Tuberculoid types INDETERMINATE
 Borderline type
 Lepromatous type

TUBERCULOID

PURE NEURITIC LEPROMATOUS BORDERLINE

Clinical feature
 Diagnosis
History

 Patients bio data : name , age , sex , address

 Presenting complaints
 Family history of leprosy
 Contact with leprosy cases
 Previous history of treatment of leprosy ,if any
 Diagnosis

Clinical Examination

 Physical examination may include:

A thorough inspection of the body surface (skin)
Palpation of commonly involved superficial nerves:
1. Ulnar nerve
2. Greater auricular nerve
3. Lateral; popliteal nerve
4. Dorsal branch of radial nerve
Testing for:
1. Loss of sensation : heat , cold, pain, touch
2. Paralysis of muscles of hands and feet.
 Diagnosis

Bacteriological examination
 Skin smears
 Nasal smears or blows
 Nasal scrapings
Diagnosis

Bacterial index

 Objective way of monitoring benefit of treatment.

 According to Ridley’s Logarithmic Scale , it ranges from 0
to 6 + and is based on the no. of bacilli seen in an
average microscopic field.
B 0 stands for no bacilli in any of 100 oil immersion filed.
Bacteriological index (BI): grading 0 to 6
Diagnosis
Morphological index

 MI is calculated after examining 200 pink stained free

standing bacilli.
 % of solid staining bacilli in a stained smear is referred to
as MI.
 It is valuable indicator of the patient’s response to treatment
during the first few months and helps to signal drug resistance.

 SOLID FRAGMENTED GRANULAR PERCENTAGE : similar to MI

but more sensitive indicator of the patient’s response to treatment.
Records % of solid , fragmented and granular bacilli .
Diagnosis
Biopsy

 Usually resorted to when there is high clinical suspicion

but the other test are unyielding.

 It also gives information about bacterial content of

skin.
 Diagnosis
Immunological tests
 Test for CELL MEDIATED IMMUNITY (CMI) :
 LEPROMIN TEST

 Test for Humoral antibodies (serological tests) :

 FLA –ABS(Fluorescent Leprosy Antibody Absorption) test : used for detecting subclinical
infections.92.3% sensitive and 100% specific in detecting specific antibodies in all types of leprosy
irrespective of type and duration of disease.

 Monoclonal antibodies

 Others: ELISA
 Diagnosis
Lepromin test
 Method: performed by injecting 0.1ml of lepromin into
inner aspect of the forearm. The reaction is read at 48 hours
and 21 days.
Two types of reaction have been described:
 EARLY REACTION (FERNANDEZ REACTION):
 An inflammatory reaction develops within 24 or 48 hours
and this tends to disappear in 3 to 4days. If the diameter
of the red area is more then 10 mm, the test is considered
positive.
 Indicatingwhether or not a person has been sensitized by
exposure to an infection by leprae bacilli .
 Diagnosis
Lepromin test (contd..)
 LATE REACTION (MITSUDA REACTION) :
 Characterizedby the appearance of a nodule which
becomes apparent in 7 to 10 days and reaches its
maximum in 3 to 4 weeks, The test is read at 21 days.

 Ifthe nodule is more than 5 mm it is considered

positive. It is induced by the bacillary component and
indicated cell mediated immunity.

 In the first 6 months of life most children are

lepromin negative.
 Diagnosis

Lepromin test

 Value of lepromin test :

 Not a diagnostic test.
 Useful tool for evaluating the immunity status of leprosy patients.
 Aid to classify the type of disease.
 Estimating the prognosis.
 Strongly positive in a typical Tuberculoid cases and getting weaker towards
the lepromatous end, the typical lepromatous case being lepromin negative
indicating failure of CMI.
 Greatest drawback being high false positive and false negative cases.
Diagnosis and Treatment of Leprosy
 LEPROSY CONTROL

Goals :
 To interrupt transmission of the
infection
 To treat patients in order to
achieve their cure
 To prevent the development of
associated deformities.
 LEPROSY CONTROL

A. Medical measures
1. Estimation of the problem
2. Early case detection
3. Multidrug therapy
4. Surveillance
5. Immunoprophylaxis
6. Chemoprophylaxis
7. Deformities
8. Rehabilitation
9. Health education
B. Social support
 MEDICAL MEASURES
• Estimation of the problem

To define the size of the problem or disease load in community by surveys.

• Early case detection

The aim of case detection is to identify and to register all cases of leprosy as soon
as possible after they become evident.
 MEDICAL MEASURES

Multidrug treatment

In the absence of effective primary prevention by a leprosy vaccine , leprosy

control is based on effective multidrug chemotherapy (secondary prevention).

Objectives of multidrug chemotherapy –

To interrupt transmission of the infection in the community by sterilizing

infectious patients as rapidly as possible with bactericidal drugs.

To ensure early detection and treatment of cases to prevent deformities.

To prevent drug resistance.

 Important points :

1. MDT is not contraindicated in patients with HIV infection.

2. MDT is safe during pregnancy.

3. Drugs are excreted in breastmilk but no reports of adverse

reaction except for mild discolouration of infants skin .

4. Leprosy is exacerbated during pregnancy, it is important that MDT

is continued.
 MEDICAL MEASURES

Duration of treatment

1. Multibacillary leprosy – MB blisterpacks for 12 months ,

within 18 months.

2. Paucibacillary leprosy- PB blisterpacks for 6 months, within

9 months
 MEDICAL MEASURES
Immunoprophylaxis

 Till date there is no effective vaccine against leprosy.

 BCG vaccine – trials in different population groups with BCG
vaccine either alone or in combination with other vaccine
(from killed M.leprae or atypical mycobacteria), have shown
protective efficacy ranging between 28% and 60%.
 MEDICAL MEASURES
Deformities
 Asa single disease entity leprosy is the foremost cause of
deformities and crippling.
 Approx.35% of cases who are not properly treated at an early
stage develop deformities of hands and feet.
 MEDICAL MEASURES

Prevention

 Measures include care of dry and denervated skin of palms and soles.
 Treating wounds, ulcers, and cracks in palms and soles.
 Use of protective gloves and footwear.
 Prevent joint stiffness in case of paralysis.
 Protection of eyes.
 Periodic check up for progression of disease.
 MEDICAL MEASURES

Rehabilitation

 Includes :

1. for reducing the impact of disability for an individual .

2. enabling him/her to achieve independence .

3. social integration.

4. a better quality of life and self actualization.

 MEDICAL MEASURES
Health education
 Health education aims at ensuring community participation.
 It should educate people on the true facts about leprosy and removes superstition and
the social stigma associated with leprosy.
 The public should be made aware that:
a) leprosy is not a hereditary disease; it is a bacterial disease like tuberculosis.
b) it is curable
c) not all leprosy patients are infectious
d) regular and adequate treatment is essential to obtain cure and prevent
disabilities
e) the patient needs sympathy and social support
 SOCIAL SUPPORT

 chemotherapy alone is not likely to solve this problem

 The economic and social problems of the patient and his
family should be identified and met.
 This may take various forms depending upon the local
situation, e.g.,
1. assistance to the patient to travel to and from the clinic;
2. help to the needy families in terms of food grains,
clothes,
3. care of children and their education,
4. programs such as slum improvement, etc.
 Anti leprosy activites in India

 1874 – mission to leprosy was found by Baily at Chamba

in the Himachal Pradesh.(now in Purulia in West
Bengal).
 The National Leprosy Control Programme (NLCP) was
launched in 1954 to provide a common platform to
discuss heir problems and share their experiences.
 Other Organisations :
 Hind Kusth Nivaran Sangha (1925)
 Gandhi Memorial Leprosy Foundation(1951)
 National leprosy organization (1965)
 WORLD LEPROSY DAY 2021 Theme
#BeatLeprosy  #EndStigma 
Advocate for #MentalWellbeing

Last SUNDAY Of JANUARY is

celebrated annually as “WORLD
LEPROSY DAY”.

WORLD LEPROSY DAY 2022 THEME

#United4Dignity

- This year, the “United for Dignity” campaign draws our attention for unity in honoring the dignity of people who
have experienced leprosy by sharing their empowering stories and advocating for mental wellbeing and the right to
a dignified life free from disease-related stigma.