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PubMed2000

Progression of eye disease in "cured" leprosy patients: implications for understanding the pathophysiology of ocular disease and for addressing eyecare needs.

BACKGROUND: Ocular damage in leprosy is due either to nerve damage or infiltration by mycobacteria. There is currently little information about the magnitude and nature of incident ocular pathology in cured leprosy patients. This information would increase our understanding of the pathophysiology of ocular involvement in leprosy and help in developing programmes to address the eyecare needs of leprosy patients who have been released from treatment. The cumulative incidence of leprosy related ocular pathology and cataract was measured during an 11 year follow up period in cured leprosy patients released from treatment in Korea. METHODS: In 1988 standardised eye examinations were performed on 501 patients in eight resettlement villages in central South Korea. In May 1999 standardised eye examinations were repeated in this population. RESULTS: Among the patients in whom there was no sight threatening leprosy related ocular disease (lagophthalmos, posterior synechia, or keratitis) in 1988, 14.7% developed one or more of these conditions. Overall, among those with no vision reducing cataract in 1988, 26.4% had developed a vision reducing lens opacity in at least one eye. Among patients examined in both 1988 and 1999, 14.3% developed visual impairment and 5.7% developed blindness. CONCLUSION: This study demonstrates that leprosy related ocular pathology progresses in some patients even after they are cured mycobiologically. The progressive leprosy related lesions are the result of chronic nerve damage; ocular lesions due to infiltration by Mycobacterium leprae did not develop. Based on the factors found to be associated with development of the most visually significant findings (posterior synechia, keratitis, and cataract) certain patients should be targeted at discharge for active follow up eye care. We suggest that patients with lagophthalmos (even in gentle closure), trichiasis, small pupils, and posterior synechiae should be screened regularly for the development of lagophthalmos in forced closure, keratitis, and cataract.

Adult↗
PubMed1989

The role of nerve biopsies in the diagnosis and management of leprosy.

Skin and nerve biopsies from 81 patients clinically suspected to have leprosy were studied. Histologically 54% of the patients showed leprosy. Both nerve and skin biopsies were histologically diagnostic of leprosy in 64% of these cases while 32% were diagnostic in the nerve but not skin biopsy. In the 11 patients with multibacillary leprosy (BI greater than or equal to 2) a multibacillary picture was seen in all nerve biopsies while 8 patients exhibited a paucibacillary leprosy of the skin and a multibacillary leprosy in the nerve. The present results emphasize that leprosy is a disease of peripheral nerves and that diagnostic criteria other than skin parameters is important to reach a proper diagnosis. The evident possibility of having patients with a multibacillary leprosy in peripheral nerves and paucibacillary in skin emphasize the need of clinical studies to clarify the criteria for the diagnosis of paucibacillary leprosy and the drug regimen for this group of patients.

Adolescent↗
PubMed1991

Squamous cell carcinoma in chronic ulcers in leprosy: a review of 38 consecutive cases.

The histories of 38 consecutive cases of squamous cell carcinoma (SCC) arising in chronic ulcers of leprosy patients treated between 1981 and 1990 at the McKean Rehabilitation Centre, Northern Thailand were analysed retrospectively. The study included 37 individual patients; 29 males and 8 females. The average age was 60 years, the average duration of leprosy was 34 years and the average duration of ulcers was 12 years. Most patients (76%) came from leprosy settlements. Patients with borderline-tuberculoid (BT) leprosy were most commonly affected (63%), followed by lepromatous (LL) leprosy (21%) and borderline-lepromatous (BL) leprosy (16%). Four patients (11%) had histories of SCC on other extremities. Metastatic spread was observed in 2 cases (5%), both instances leading to death. The commonest site of involvement of SCC was the foot, but it was seen on the knee in 1 patient and on the hand in 2 others. The incidence rate of SCC in the group at risk (leprosy patients with disability grading 1 and 2) is calculated as being 0.79:1000 per year. SCC was seen in 1.8% of all cases admitted for ulcer care at the Centre. Treatment is by radical amputation. SCC in chronic ulcers in leprosy patients cannot be considered rare and emphasizes the need for an active policy of disability prevention in leprosy programmes.

Adult↗
PubMed1994

Transmission of health information on leprosy from children to their families in an urban centre.

A health education study utilizing a homework assignment was carried out in a private secondary school in Bangalore, South India, to determine whether health information about leprosy would be transferred from children to their families. After a pre-test questionnaire on knowledge and attitude about leprosy was administered to 3 Standard VII classes and their family members, a different comprehensive health education session was given to each class: (i) leprosy plus a homework assignment; (ii) leprosy alone; and (iii) tuberculosis alone. A post-test questionnaire was administered to all participants 1 month later. Of the 118 children and 229 family members who entered the study, almost 80% of the participants completed it. The children in the leprosy-educated groups showed significant improvement in knowledge compared with controls, but no change in their attitude towards leprosy. Although post-test responses of household members showed modest improvement in knowledge about leprosy, attitudes remained the same or worsened. The homework assignment did not appear to improve the transmission of health information to household members. This study showed that the knowledge level of family members in South India could be improved modestly by educating their children about leprosy. However, attitudes towards leprosy were unaffected or worsened.

Adolescent↗
PubMed2000

Which physical signs help most in the diagnosis of leprosy? A proposal based on experience in the AMFES project, ALERT, Ethiopia.

As integration of leprosy control programmes proceeds, general health staff will have responsibility for the diagnosis of most new cases of leprosy. The training required by these workers has not yet been set out in detail. In this paper the criteria for making the diagnosis of leprosy in the AMFES cohort of 594 new cases are examined. Since this study does not include details of suspects in whom leprosy was excluded on clinical grounds, true sensitivity and specificity values cannot be calculated, but the positive predictive value of the diagnostic criteria can be measured. Sensory loss in a typical skin patch is the most important sign of early leprosy, but was not present in 132 (49%) of the 268 cases with a positive skin smear. Thickening of the ulnar nerve is a valuable sign of leprosy in Ethiopia. It can be taught to health workers, who can practise by examining their own ulnar nerves. It is more likely to be present than nerve function impairment and is particularly important when skin smears are difficult to do or are unreliable. We recommend that five basic signs are used, the presence of any two being diagnostic of leprosy: Skin lesion(s) consistent with leprosy. Loss of sensation in such a lesion. Thickening of either ulnar nerve. Loss of sensation in the palm of the hand or the sole of the foot. The presence of acid-fast bacilli in skin smears. Exact policies for the diagnosis of leprosy should be worked out and validated for each national programme.

Cohort Studies↗
PubMed2001

Capture-recapture method to assess the prevalence of disabled leprosy patients.

The capture-recapture technique was applied in estimating the prevalence of disabled leprosy patients in four States in Northern Nigeria. A two-sample capture-recapture method, using data from hospital admissions during 1997 and 1998 in three leprosy referral hospitals, and from a sample survey on leprosy patients with disabilities in the clinics in 1999. In the sample, 1395 (ex) leprosy patients were found, 393 with a disability. Of these 393 patients, 47 had been admitted during 1997 and 1998 to one of three leprosy referral hospitals. In these hospitals, 151 individuals from the 24 study Local Government Areas (LGA) in four states of Northern Nigeria were admitted in 1997 and 1998. Using the Peterson estimator, we calculated the number of unknown disabled leprosy patients in the studied LGAs to be 1262 (95% confidence interval 991-1533). This was nearly four times greater than the field reported figure. The capture-recapture method can be applied in a leprosy care programme. Limitations of the method are the completeness of reporting after invitation in the field, as well as the probable biased sample of leprosy patients admitted to hospital. Our finding implies that relying on patients to report for prevention of disabilities and rehabilitation to the clinics, causes the real size of the problem to be underestimated by a factor of 3-4. We recommend the use of a special 'care' register for disabled leprosy patients to better address their needs for prevention of disabilities and rehabilitation.

Adolescent↗
PubMed1976

Integrated surveys as a tool for early case detection in leprosy control programme.

A project for total leprosy case detection particularly early leprosy cases was undertaken in Wardha District which has a rural population of about 6 lacs in 905 villages, through an integrated survey with the help of all health workers like Leprosy Technicians, Sanitary Inspectors, Co-ordinators, Malaria Workers, Smallpox Vaccinators and Auxillary Nurse Midwives. The training given to the Non Leprosy Health Worker was for a period of 3 days making them just fit to suspect all leprosy cases. The final diagnosis was to be made by the fully trained Leprosy Technicians. The surveys were conducted in batches of 3 to 4 workers. Surveys were conducted for 4 weeks at a stretch and working for 5 days every week. Every year two such integrated surveys were conducted. From November 1973 to December 1975, four such surveys were undertaken. During the other period, Leprosy Technicians were conducting the normal surveys. It was found that through these integrated survey it is possible to undertake the survey of all the villages once in two years and the case detection rate at the end of the 4th survey was found to be 85.5% of the estimated cases in the rural areas. Normally, it would have taken about 5 years to complete the survey of all the villages by the Leprosy Technicians alone, and the case detection rate could not have been more than 70 to 75%. Through this programme, Leprosy patients in every early stages have been detected. The paper discusses the methods, planning and the results obtained.

Adult↗
PubMed2000

Epidemiology of leprosy in Taiwan; its pattern in children.

OBJECTIVE: To study the epidemiology of leprosy in children in Taiwan. SETTING: Taiwan, with a population increase from 3.3 to 21.7 million, several tides of immigration and national leprosy control programs, from 1910 to 1997. DESIGN: To collect and analyze the documents of Taiwan leprosy surveys and charts of the National Leprosy Control Center. PATIENTS AND MEASUREMENTS: Cumulative and new number of all-age and pediatric-age patients, prevalence rates, new case detection rates, and results of skin bacterial smears. RESULTS AND CONCLUSIONS: The prevalence rates of all-age leprosy ranged between 1.54 and 3.22 per 10,000 population. The proportion of children among all-age patients reached the highest of 4.93% in 1966, dropping to 0% in 1984 and thereafter, until 1988 and 1991 when two and one pediatric-age patients appeared, respectively, following the influx of immigrants from leprosy-endemic countries. The rise and fall of new patients younger than 15 years and 15 years or older were slightly correlated (r = 0.935, p < 0.001). Detection and confirmation of leprosy in children are usually belated. Physicians should still be acquainted with the clinical diagnosis of leprosy since sporadic cases of leprosy can reappear, particularly among children coming from endemic countries.

Adolescent↗
PubMed2001

[New cases of leprosy at the Marchoux Institute: a comparative study 1988-1997].

BACKGROUND: The prevalence of leprosy had declined greatly over the last decade. The purpose of this work was to determine whether changes in the epidemiology, clinical and bacteriological patterns occurred among patients with leprosy treated at the Marchoux Institute in 1988 and in 1997. PATIENTS AND METHODS: We conducted a descriptive cross-sectional study, reviewing retrospectively all files of patients with leprosy seen in 1988 in comparison with a prospective series of leprosy patients seen in 1997. Only new cases of leprosy, prior to treatment and with skin and/or nervous lesions irrespective of the bacilloscopy results, were included in the two series. RESULTS: We included 93 patients among 246 patient files in 1988. There were 119 new cases in 1997. The following variables showed changes: mean delay to consultation (41.2 months in 1988 versus 26.1 months in 1997; patient's suspicion of having leprosy (93 patients in 1988 versus 22 in 1997); notion of contact (35 cases in 1988 versus 45 in 1997). Multibacilli leprosy predominated over paucibacilli leprosy in 1988 (51 versus 42 cases). This trend was inverted in 1997 (44 versus 75) (p<0.009). Patients with grade 2 handicap were more numerous in 1988 (20 cases versus 2 cases, p<0.001). CONCLUSION: These findings demonstrate a change in the epidemiology, clinical and bacilloscopic pattern of patients with leprosy from 1988 to 1997.

Adult↗
PubMed2001

Effect of HIV infection on the clinical spectrum of leprosy in Maiduguri.

The clinical features associated with different classes of leprosy patients co-infected with HIV in Maiduguri was studied and the classification of leprosy was done clinically and bacteriologically using Ridley-Jopling classification and bacteriological index respectively. The cases were classified as paucibacillary (Tuberculoid--TT and Borderline Tuberculoid--BTT) and multibacillary (Borderline Borderline--BB, Borderline Lepromatous BL and Lepromatous Leprosy--LL) leprosy. Eleven (10.5%) of 105 leprosy cases were HIV-seropositive comprising of 7 males and 4 females. Age range was 15 and 62 years. Among the HIV seropositive patients, those with paucibacillary (PB) leprosy were 6 (TT-1, BT-5) while multibacillary (MB) leprosy 5 (BB-1, BL-2, LL-2). The predominant clinical features were clawing of fingers (64%), ulcerations (64%), hand muscle atrophy (55%) and clawing of toes (45%). Some clinical features of paucibacillary leprosy such as sensory and hair losses (as is also seen in HIV negative patients) occurred in increased frequency in HIV positive patients belonging to the multibacillary class. The HIV infected leprosy patients are more likely to manifest advanced stages of the disease than the HIV seronegative patients.

Adolescent↗
PubMedDate not supplied

Immunologic aspects of leprosy with special reference to the study of immunoglobulin E.

The serum levels of IgG, IgM, IgD and IgE have been determined in normal subjects, individuals suffering from ascariasis and filariasis, and in leprosy patients. Allergic and parasitic diseases were excluded in these normal subjects and in leprosy patients before they were taken for the study of their serum IgE. The circulating IgG was significantly raised in both tuberculoid and lepromatous forms of leprosy and also in filariasis; IgM was significantly elevated in only the lepromatous form of leprosy, ascariasis as well as in filariasis; while IgA was exclusively raised in both forms of leprosy. IgD was detected in the sera of more subjects with ascariasis and filariasis than in normal individuals and leprosy patients. The mean level of serum IgE in 35 normal Indian subjects was 1,025 I.U. per ml, 9 of them (25%) having serum IgE concentrations above 700 I.U. per ml. The highest mean level of serum IgE was found in ascariasis (7,328 I.U. per ml), followed by leprosy (5,180 I.U. per ml), and filariasis (4,244 I.U. per ml). Furthermore, no significant difference between the mean serum IgE levels of tuberculoid and lepromatous leprosy patients was observed. Although the rise of serum IgE level in these parasitic diseases, as well as in leprosy, was spectacular, the augmented synthesis of this unique class of immunoglobulins was not invariably present in all patients. The results have been discussed on the basis of recent ideas on immunoglobulin synthesis.

Adolescent↗
PubMed2002

[Eradication of leprosy and public health. Vaccination and multidrug therapy].

Leprosy is a disease, which still affects large populations in the developing countries particularly in Africa, Asia and Latin America. For the last 15 years significant advances have been made towards leprosy elimination. The most effective strategy for leprosy control is an early identification of cases and an effective treatment with multidrug therapy (MDT). The vaccination against leprosy plays only an additional role. There are two possible approaches to develop vaccine against leprosy. One is to produce a vaccine based on organisms related to M. leprae, such as: BCG, ICRC bacillus, Mycobacterium w, Mycobacterium vaccae, Mycobacterium habana. However, these organisms related to M. leprae are not very promising in experimental animal studies. In 1970s a new vaccine was prepared based on killed M. leprae. This vaccine, tested alone and together with BCG revealed little impact on increasing vaccine efficacy. The success in cloning and expressing the M. leprae genome in E. coli created the possibility of moving towards a second generation vaccine using peptide antigens. Up till now only MDT has essential impact on decline of global leprosy prevalence. Out of 122 endemic countries in 1985, 107 countries have reached elimination of leprosy at country level. At the end of 2000 leprosy was a public health problem only in 15 countries (prevalence rate > 1/10.000). Currently leprosy remains a problem mainly in 6 major endemic countries. Among these, India alone accounts for 64% of prevalence and 78% of detection worldwide.

Africa↗
PubMed2004

Leprosy case detection using schoolchildren.

An innovative method that combined awareness creation with screening of high school students by their peers was undertaken in 26 randomly selected schools in the project area of the Schieffelin Leprosy Research and Training Center, Karigiri, Vellore, India. This method entailed educating teachers and student leaders in grades 8-12 about leprosy and how to suspect leprosy among their peers. The student leaders in turn conducted a similar awareness programme for their peers and encouraged them to report if they suffered from any skin problem or skin lesion. Based on the reporting by their peers, the class leaders prepared a 'suspect list'. Within a fortnight of the awareness program, a trained leprosy worker visited the school and examined all the students on the 'suspect list'. Those diagnosed to have leprosy were referred to a medical officer, who then confirmed the diagnosis and initiated treatment. Among the 23,125 students enrolled in the 26 randomly selected schools, 234 student leaders were educated about leprosy and trained to detect suspect lesions among their peers. A total of 2200 (9.5%) children reported with skin lesions to their leaders and after screening by a leprosy supervisor and confirmation by a medical officer, 14 new cases (NCDR 6.05/10,000) were detected. This rate was found to be comparable with case detection rates of annual school surveys done during the National Leprosy Eradication Programme (NLEP), when all schoolchildren were examined. The paper suggests that schoolchildren can be used effectively in leprosy case detection and this method has the additional advantage of creating awareness among them, their teachers and communities.

Adolescent↗
PubMedDate not supplied

People's perception of leprosy--a study in Delhi.

Leprosy is considered to cause more social than medical problems. The present study focussed on this aspect in order to investigate the level of awareness among people--about their attitude towards the disease and the afflicted. The results are based on interviews with 104 persons in Delhi. The sample data revealed that the level of knowledge of leprosy was inadequate. The cause of the disease was known to 44.2% of those interviewed, while 31.7% were completely ignorant; 6.7% believed it to be the consequence of an individual's past misdeeds, and 1.9% believed it to have been caused by divine curse. 63.1% were aware that the disease is curable. 73.1% of the persons interviewed sympathised with leprosy-afflicted beggars. 61.5% favoured leprosy patients to stay with their families and within their communities. 67.3% felt that the cured could marry, while 25% felt that the leprosy-afflicted should stay in leprosy colonies away from the society. 54.8% were reluctant to employ the leprosy-afflicted as domestic help, and 31.7% were reluctant to establish matrimonial relationship with a family having a leprosy-afflicted person. The data call for intensification ofpublic awareness regarding the aetiology of leprosy. Positive and scientific information should be disseminated to minimize the social prejudices associated with the disease.

Adult↗
PubMed2004

Factors associated with sight threatening lesions of leprosy in patients on multidrug therapy.

One hundred and six consecutive patients (old and newly diagnosed) attending the leprosy clinic at Guru Teg Bahadur Hospital, Delhi, underwent a detailed ophthalmic examination to identify factors associated with the prevalence of sight threatening lesions of leprosy so as to delineate a sub-group of patients who should continue under active ophthalmic surveillance to prevent blindness. All of them were receiving multidrug therapy as recommended by WHO. Demographic data, systemic parameters and ophthalmic lesions attributable to the disease were endorsed on to a proforma. The data were analysed by chi-square test, discriminant analysis and multivariate regression analysis to isolate factors that could be associated with sight threatening lesions of leprosy. In 106 leprosy patients 212 eyes were examined; sight threatening lesions were found in 37 eyes (17.4%). The comea was involved most commonly (78.3%). The lesions were still present in 15.8% of patients who had completed multidrug therapy. Leprosy related visual impairment was seen in 2.3% eyes and blindness in 0.9% eyes. Factors significantly associated with sight threatening lesions included female gender, multibacillary leprosy, increasing duration of leprosy, thickened corneal nerves, subepithelial punctate corneal opacities and presence of any academic lesion of leprosy. On multivariate and discriminant analysis, female gender, thickened corneal nerves and duration of leprosy > 7 years were significantly associated with sight threatening lesions.

Adolescent↗
PubMed2005

Assessment of the quality of leprosy services from the clients' perspective in Thailand.

To assess the quality of the leprosy service in health facilities from the clients' perspective, qualitative data collection methods, i.e. semi-structured interviews, focus group discussions (FGDs) and priority cards, were conducted in six health facilities located in all regions of Thailand. A total of 29 patients were interviewed and three focus group discussions involving 20 patients were carried out. In addition, six health staff and six community members were interviewed. The results show that patients delayed months to years before they went to a public health facility. This is due to the poor knowledge about leprosy. Most of the interviewed patients tried to get rid of the skin symptoms at home, using topical medicated cream or herbs. Distance was not regarded as a problem, because most patients go to nearby district hospitals. In district hospitals misdiagnosis is still common. More than half of leprosy patients said they did not receive any information about leprosy before they were diagnosed. Travel costs seem to cause problems for a few poor and aged patients who needed someone to accompany them. Patients at district and provincial hospitals complained that the waiting times to consult staff were too long. In most health facilities, privacy during examinations was not adequate. Patients placed a priority on health staff being friendly and respectful to them. When patients were asked to list their priorities of the quality of services, they considered the attitude of health staff, low costs to go to the leprosy services, adequate attention to POD and adequate information to leprosy patients on their disease, as their top four items. Important recommendations resulting from the study were: (1) health education to the public has to be strengthened; (2) training of health staff to minimize doctors' delay; (3) good attitude of health staff towards leprosy patients should be sustained; and (4) leprosy services in district and provincial hospitals should be improved as a one-stop service for leprosy patients.

Health Care Surveys↗
PubMed2005

Study of apoptosis in skin lesions of leprosy in relation to treatment and lepra reactions.

In leprosy on treatment, one factor contributing to the healing of skin lesions with minimal fibrosis may be apoptosis of inflammatory cells, even though apoptosis is sparse in leprosy as compared to tuberculosis. The degree of apoptosis in skin lesions of leprosy was studied by histopathologic examination (HPE) and by DNA fragmentation and electrophoresis. The effect of various parameters on apoptosis was noted in untreated disease, during treatment at 3 and 6 months, and in lepra reactions in different parts of the spectrum of leprosy. Of the 31 patients, 13 had paucibacillary (PB) and 18 multibacillary (MB) disease. Twenty one patients were in reaction: 16 had type 1 reaction and 5 had type 2 reaction. The controls included patients with non-granulomatous skin diseases; there were no normal controls, and no separate controls for cases with reaction. Apoptosis occurred more frequently in patients with leprosy as compared to the controls. In both PB & MB lesions, apoptosis was observed to increase progressively with treatment at 3 and 6 months, and was more prominent in the MB cases at 6 months of treatment. When lesions in either type 1 or type 2 reaction were compared to lesions not in reaction, a significant increase in apoptosis (p = 0.014) was found only in lesions with type 2 reaction and those which were at 6 months of treatment. The type of treatment regimen, or oral steroids given for reactions, did not significantly alter the degree of apoptosis. Our observations indicate that increased apoptosis is present in leprosy lesions and that in leprosy it progressively increases with anti-leprosy treatment up to 6 months. If the process of apoptosis in skin lesions is followed up for a longer period of time, the degree of apoptosis may be expected to decline. The study of apoptosis may help to understand the mechanism of clearance of bacilli and resolution of granulomas in leprosy patients.

Adolescent↗
PubMedDate not supplied

Epidemiological significance of indeterminate leprosy--a hospital based study.

An epidemiological analysis of 100 cases of indeterminate leprosy attending the Department of Dermatology and Venereology of Medical College Hospital, Trivandrum, is presented. It was found that indeterminate leprosy formed 13.23% of all cases of leprosy and 1.3% of all out-patients attending this department. Only 27% of patients with indeterminate leprosy were below 15 years of age. There was a predominance of males especially over 20 years of age. There was no history of contact with leprosy in any of the patients with indeterminate leprosy. All patients with indeterminate leprosy came for hypopigmented patches, suspecting leprosy. Majority had the disease for more than 6 months. Single lesion on the outer aspect of extremity was the most common presentation. The lepromin test was positive in only 2% of patients with indeterminate leprosy, while it was positive in 80% of control subjects. Three cases of dapsone resistance were suspected in this series. The epidemiological significance of the findings is discussed.

Adolescent↗