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PubMed1998

Histological studies in primary neuritic leprosy: changes in the nasal mucosa.

The nasal mucosae of 39 cases of primary neuritic leprosy (PNL) registered at Karigiri were studied histologically to determine nasal mucosal involvement in PNL and its relevance to the pathogenesis of the disease. Specific changes of leprosy were seen in 20 (51%) biopsies, ranging from macrophage granulomas with acid fast bacilli, to epithelioid granulomas and nerve inflammation. The remaining biopsies revealed chronic inflammatory changes of the mucosa or mild non-specific nerve changes. These findings show that there are widespread effects of the disease even in PNL patients in whom the disease is believed to be confined to the peripheral nerves. The findings also show that early leprosy involvement can be found in the nasal mucosa even before lesions become apparent in the skin or other parts of the body. The nasal mucosa could be one of the sites for the primary lesion in leprosy. Clinical and histological examination of the nasal mucosa may be useful and important in the early diagnosis of leprosy and especially in contacts.

Biopsy, Needle↗
PubMed2000

Modified leprosy elimination campaign (MLEC) for case detection in a remote tribal area in the State of Orissa, India.

A leprosy project was established in a difficult to reach area under guidelines of Government of India. The leprosy services were provided by Koraput Leprosy Eradication Project (KORALEP) and general health services by Primary Health Care (PHC). Leprosy elimination campaigns (LECs) were suggested by WHO to detect more cases in the community. A modified leprosy elimination campaign (MLEC), carried out utilizing the services of primary health care workers is discussed in this paper. Apart from the trained health workers, Anganwadi workers along with some literate people from the district were also included in the search teams. In all, 1543 cases were shortlisted from the suspects identified and on re-examination 576 cases were confirmed as active cases. Sixty percent of the cases detected were very early cases with two to three skin lesions. This could be achieved with a very brief training of health workers and involving village voluntary workers. MLEC was found to be a useful tool for case finding in such areas.

Adolescent↗
PubMed2000

Gender differentials in the social and family life of leprosy patients.

A study was carried out at the Leprosy Control Unit, Government Medical College, Nagpur, India, to investigate gender differentials in the social and family life of leprosy patients. The study included 486 (268 males and 218 females) leprosy patients, who were diagnosed and registered at least 1 year prior to the data collection. It was observed that leprosy patients were isolated and refrained from various activities in the family. However, the effect of disease on this isolation was significantly greater in females as compared to males. Similarly, although, men and women were both affected in terms of their social life, women suffered more isolation and rejection from the society. The current study describes the gender differentials in the social and family life of leprosy patients in Central India.

Adaptation, Psychological↗
PubMed2000

Delay in presentation and start of treatment in leprosy: experience in an out-patient clinic in Nepal.

Delayed presentation is a recognized risk factor for disability in leprosy but is the result of complex interactions between physical, social, economic and psychological factors. The present study is a response to the situation in an outpatient clinic in Nepal where the wide variation in delay in presentation was a cause for concern. A purpose-written questionnaire was used to collect information on 166 consecutive outpatient admissions. The data included demographics, the first symptom of leprosy, first actions, initial help-seeking behaviour, the reasons for finally seeking treatment and experience with professional health services. Initial analysis found a relationship between delay in presentation and age, rural environment, leprosy classification, walking time, housing not shared with another person affected by leprosy, and an inappropriate first action. The relationship with lack of education and total travel time just failed to reach significance. Further analysis identified that for the study population initial lack of awareness of leprosy and an inappropriate first action were the primary contributors to delay. Extensive and effective health education is needed to address this situation.

Adolescent↗
PubMed2000

Chemoprophylaxis of leprosy in the southern Marquesas with a single 25 mg/kg dose of rifampicin. Results after 10 years.

In 1988, a programme of leprosy chemoprophylaxis, employing a supervised, single 25 mg/kg dose of rifampicin, was implemented in the Southern Marquesas Islands. Of the 2786 inhabitants, 2751 (98.7%) were treated. In addition, 3144 South Marquesans living elsewhere in French Polynesia were administered the same chemoprophylaxis. During the following 10 years, seven leprosy patients were detected among those who had been administered chemoprophylaxis. Of these, two were very likely missed cases of leprosy, and cannot be considered a failure of chemoprophylaxis. The epidemiometric projection model, based on cases of leprosy observed in the Southern Marquesas during the 20 years preceding implementation of the programme, predicted that 17 leprosy cases could be expected in the South Marquesan population if no chemoprophylaxis were given. In fact, only five cases were detected in the treated population, a number significantly smaller than 17, suggesting that the chemoprophylaxis was 70% effective, assuming that no change of detection rate would have occurred without chemoprophylaxis. However, during the 10 years following implementation of the chemoprophylaxis programme, the detection rate in the Polynesian population that was not administered chemoprophylaxis declined by about 50%. Therefore, the effectiveness of the chemoprophylaxis was only 35-40%.

Adolescent↗
PubMed2000

Chemoprophylaxis against leprosy: expectations and methodology of a trial.

Because of the great efficacy of multidrug therapy (MDT), it had been hoped that the widespread use of MDT would bring about a rapid decrease of the incidence of leprosy. To the present, a decrease of incidence has not been observed, possibly because of the long incubation period of the disease, and because general implementation of MDT is still recent. Other reasons, such as environmental sources of infection or the role of healthy carriers in transmitting Mycobacterium leprae, cannot be excluded. Therefore, one must seek alternative or supplementary strategies, such as chemoprophylaxis. Household contacts of leprosy patients are at greater risk of developing leprosy than is the general population. Therefore, a randomized, controlled trial of chemoprophylaxis, using a single 10 mg/kg dose of rifampicin, or a placebo, is planned in nine projects in India, among the household contacts of newly detected leprosy patients. Based upon assumptions of a protective efficacy of the chemoprophylaxis of 50%, an annual incidence of 2 per 1000 contacts, a desired power of the study of 90%, and a level of significance of 95%, 15,000 household contacts will be allocated randomly by household to each arm of the study, and followed for 5 years. Considered as household contacts will be all persons living in the same household as an index case and sharing the same kitchen. Pregnant women and infants will be excluded. To be certain that transmission of the organisms from the index case cannot occur once the prophylaxis is administered, rifampicin will be administered 2 months after diagnosis of the index case. Diagnosis of leprosy will be clinical, and confirmed independently. Although household contacts usually constitute only a small proportion of the new patients detected in a control programme, their high-risk status makes them particularly appropriate for a study of the potential effect of chemoprophylaxis. Following the trial, one could evaluate the usefulness and feasibility of using the same strategy in other population-groups, based on the number of persons necessary to treat to prevent one case.

Drug Therapy, Combination↗
PubMed2000

Review of current research in the prevention of nerve damage in leprosy.

Nerve damage and the consequences of nerve damage set leprosy apart from other diseases. The irreversible motor and sensory impairments caused by leprosy lead to increasing secondary impairments long after the disease process has been arrested. Interventions that prevent, reverse or limit the impairments resulting from leprosy are, therefore, of the highest priority. Self-care has been demonstrated to be an effective means of preventing secondary tissue damage, and its implementation must now be encouraged within the framework of basic health care. Currently, a comprehensive effort has been made to address all dimensions of impairment of nerve function and its consequences, from prevention of both primary and secondary impairments to interventions in long-term nerve damage. The BANDS prospective study of a cohort of 2664 previously untreated leprosy patients in Bangladesh has provided both a valuable baseline and insight into the epidemiology of nerve damage in leprosy. This work has defined the numbers of patients who present with acute nerve damage, the numbers who are not treated, and the importance of the MB classification, and has described the simple clinical prediction rule. This study also provided the basis for the development of the three TRIPOD randomized clinical trials in Nepal and Bangladesh. Follow-up of the BANDS cohort, which is continuing, will yield more data on the natural history of nerve damage. The encouraging results from the TRIPOD trials of low-dose prophylactic steroids will be followed up, to see whether the effect is sustained over time. The TRIPOD trials are to be completed, a trial of three steroid regimens in reversal reaction is to be completed, and a number of specific research topics within the ILEP programme, INFIR, are to be developed.

Bangladesh↗
PubMed2001

Fine needle aspiration cytology (FNAC) of nerves in leprosy.

Leprosy is primarily a disease of the peripheral nerves and a technique that is simpler than nerve biopsy is required to evaluate nerve involvement, especially in pure neuritic (PN) leprosy. This study was designed to evaluate the role of FNAC of the nerve in the diagnosis and classification of leprosy. A prospective study was carried out on 25 patients with clinically active leprosy and at least one thickened peripheral sensory nerve. Nerve aspirates were evaluated by May-Grunwald-Giemsa and Fite's staining. Lepromin test, slit skin smears (SSS), skin biopsies (except PN cases) and nerve biopsies were performed and compared with FNAC. FNAC of nerve from 23 cases (92%) yielded diagnostic aspirates. Acid fast bacilli were observed in six cases by FNAC. FNAC and nerve pathology were equally comparable with the other parameters evaluated. Based on the results, cytological criteria were developed for interpreting nerve aspirates and the cases were classified as paucibacillary (18), BB (2), BL (2), LL (1) and non-diagnostic (2). All PN cases showed diagnostic paucibacillary type cytology. FNAC of the nerve yields diagnostic aspirates in leprosy comparable with nerve pathology and the proposed cytological criteria may be useful in classification of nerve aspirates.

Adult↗
PubMed2001

Should nutritional status evaluation be included in the initial needs assessment of leprosy patients with disability prior to socio-economic.

Because of the large numbers of leprosy patients with disability and the limited resources available, it is important that socio-economic rehabilitation (SER) is targeted towards those who are most in need. Towards this purpose, current assessments of leprosy patients prior to initiating SER include the evaluation of income, assets and household possessions. Conspicuously absent is the nutritional assessment of the patient. In the absence of weight loss associated with illness, population studies indicate that undernutrition reflects poor socio-economic conditions. In this study of 151 cured leprosy patients with disability, 57% of the patients were found to be undernourished using body mass index (kg/m2) derived from body weight and height, and 10% of the patients were severely undernourished (grade III). Undernutrition in the patients was poorly though significantly correlated with personal income (r = 0.18, P < 0.05). Total household income, reported amount of money spent on food and estimated cereal intakes were not correlated with the BMI of the patient, possibly due to reporting bias and other methodological issues. We propose the inclusion of nutritional status evaluation by anthropometry as part of the initial screening of leprosy patients prior to instituting SER. We believe that this simple and objective evaluation can add to the assessment of 'threat' of economic deprivation or actual economic 'dislocation', and thus help in the prioritization of leprosy patients for SER.

Adult↗
PubMed1999

Leprosy in England and Wales.

This paper reviews cases of leprosy notified in England and Wales to the Central Leprosy Register since its inception in 1951. Leprosy remains a rare condition in England and Wales, with fewer than ten cases notified on average in recent years. No definite case of indigenously acquired leprosy has been reported since the disease became notifiable. Although only a small number of patients present each year, leprosy remains a debilitating disease, and the unfamiliarity of clinicians with this condition can lead to delays in diagnosis and undernotification.

Adult↗
PubMed1999

Disease and disease control. International Leprosy Congress, Beijing, 7-12 September 1998. Workshop report.

Four workshops were conducted during the congress under the disease control theme. The workshops were on the issues of defining disease and antibacterial therapy, early case detection, sustaining leprosy control in low endemic situations, and the prevention of disability. These workshops spanned the spectrum of disease and its consequences through from early detection, the definition of disease to the prevention of disability. All of these topics being important contemporary issues challenging leprosy control programmes world wide. Despite the broad spectrum of the topics it was interesting to see that a number of important themes emerged which were common to all topics. It is possible to identify five major themes arising from the output of the workshops which are now described below. Each of the workshops adopted broad and comprehensive approaches to their topic. In the past, there has been narrowness in defining disease in terms of the need for chemotherapy. The approach taken in the workshop now is for a much more comprehensive approach looking at all the consequences of the disease process rather than the requirement for antibacterial chemotherapy. Similarly broad approaches were taken to low endemic situations, considering comprehensive approaches which are inclusive rather than exclusive. Disability prevention also continues this same theme of comprehensive approaches based on multidisciplinary involvement in prevention of the consequences of the disease process. The second major theme to be identified in the output of the workshops was the importance of relevance to patients and people affected by leprosy. It is no longer adequate to view programmes in terms of their acceptance to those running the programmes. Control programmes must be acceptable to the people they are designed to benefit. This even impacts on definitions of disease in terms of what matters to patients rather than only restricting this to disease pathology. Similarly, approaches to disability prevention are not merely about measurement of impairments due to nerve function deficit but rather consider the abilities and functions which are most important to the individuals affected. The third theme which spans all of the workshops is the need to develop partnerships with others in addressing the challenges of leprosy today. Each workshop identified important groups with which partnerships need to be developed included local patient groups, voluntary associations and primary health care services. All of these have a role to play, from early case detection right through to the prevention of disability and the sustaining of control under low endemic situations. The fourth important theme is sustainability of programmes which need to be developed for the long term benefit of those affected by disease rather than short term goals. Again, this impacts an area such as case detection methods which need to be sustained in the long term. Approaches such as intensive case detection through mass survey are not sustainable given changes to the patterns of disease, whereas involvement of communities and community participation in the process of early case detection is a much more sustainable approach. This is important, as programmes attain low endemic status and is also important in preventing disabilities where the progressive nature of secondary impairments following primary impairments may be lifelong. The final theme is that of the importance of training, as each area is recommending new approaches to be taken and for new people to be involved in leprosy programmes. The implications are that those to be involved need to be trained and that the training requirements will be different from those of the last ten years. Training programmes will need to adapt to a wider range of individuals and groups being involved in programmes and to much more comprehensive approaches. These implications for training are profound and training centres and training programmes rapidly

China↗
PubMed1999

Lot quality assurance sampling (LQAS) for monitoring a leprosy elimination program.

In a statistical sense, prevalences of leprosy in different geographical areas can be called very low or rare. Conventional survey methods to monitor leprosy control programs, therefore, need large sample sizes, are expensive, and are time-consuming. Further, with the lowering of prevalence to the near-desired target level, 1 case per 10,000 population at national or subnational levels, the program administrator's concern will be shifted to smaller areas, e.g., districts, for assessment and, if needed, for necessary interventions. In this paper, Lot Quality Assurance Sampling (LQAS), a quality control tool in industry, is proposed to identify districts/regions having a prevalence of leprosy at or above a certain target level, e.g., 1 in 10,000. This technique can also be considered for identifying districts/regions at or below the target level of 1 per 10,000, i.e., areas where the elimination level is attained. For simulating various situations and strategies, a hypothetical computerized population of 10 million persons was created. This population mimics the actual population in terms of the empirical information on rural/urban distributions and the distribution of households by size for the state of Tamil Nadu, India. Various levels with respect to leprosy prevalence are created using this population. The distribution of the number of cases in the population was expected to follow the Poisson process, and this was also confirmed by examination. Sample sizes and corresponding critical values were computed using Poisson approximation. Initially, villages/towns are selected from the population and from each selected village/town households are selected using systematic sampling. Households instead of individuals are used as sampling units. This sampling procedure was simulated 1000 times in the computer from the base population. The results in four different prevalence situations meet the required limits of Type I error of 5% and 90% Power. It is concluded that after validation under field conditions, this method can be considered for a rapid assessment of the leprosy situation.

Computer Simulation↗
PubMed1999

Review of leprosy control activities in Yemen.

Leprosy control activities in Yemen are reviewed historically and up to the present time. Since 1983 the World Health Organization's multidrug therapy has been used in the National Leprosy Control Programme. Current activities are carried out in 63 leprosy clinics distributed all over the country and staffed by trained primary health care workers and medical assistants. In Yemen leprosy prevalence has declined from 1400 per 10,000 population in 1990 to 647 in 1997. Over the same period, new case detection rates per 10,000 population increased from 185 to 517. A backlog of leprosy cases continues to transmit the disease in Yemen.

Ambulatory Care Facilities↗
PubMedDate not supplied

Immunologic aspects of leprosy as related to leucocytic isoantibodies and platelet aggregating factors.

The incidences of various iso- and autoantibodies in a random population of 112 unselected leprosy patients is presented. Low titers of leucocytic isoantibodies and platelet aggregating factor were detected in the sera of a variable number of such patients. The leucoisoagglutinins were found in 8% of the sera of tuberculoid as well as lepromatous leprosy patients, whereas the leucoisocytotoxins were detected in a larger percentage of the lepromatous (40%) as well as tuberculoid (28%) cases. The platelet aggregating factors (PAF) were positive in 51.2% and 45% of lepromatous and tuberculoid cases respectively. Of the 21 positive sera for PAF, the antiplatelet factor by antihuman globulin consumption test could be demonstrated only in 66.6% and 50% of lepromatous and tuberculoid sera respectively. To study the frequencies of these newly detected antibodies or antibody-like factor and to compare their occurrences with other well-documented autoantibodies present in the sera of leprosy patients: cryoglobulins, antinucleoprotein antibody and thyroglobulin autoprecipitin were also studied in the sera of the same population of leprosy patients. It has been observed that the simultaneous occurrence of all these auto- and isoantibodies in the serum of one patient is a rare phenomenon. Leucocytic and platelet counts of these patients having antibodies against leucocytes and platelets were found to be within normal limits. Accordingly, it is suggested that the low levels of antileucocyte antibody and antiplatelet factor are probably harmless to the hosts. On the other hand, it is postulated that these antibodies may act as enhancing factors by being specifically adsorbed on the lymphoid cells, thus rendering them unresponsive to mitogenic stimulus in vitro. From these studies it seems that leprosy, especially the lepromatous type, is associated with some of the serological features suggestive of an autoimmune aberration.

Antibodies, Antinuclear↗
PubMed1976

Plasma factors in delayed-type hypersensitivity. Augmentation of lymphocyte responses in borderline leprosy reactions.

The phytohaemagglutinin-induced responses of lymphocytes were found to be inhibited by plasma from patients with leprosy when compared with their responses in pooled serum from healthy donors. When patients developed reversal reactions, the initial inhibitory effect of their plasma was replaced by an augmentary effect on the responses to phytohaemagglutinin. The period of augmentation coincided with that of the reversal reaction in patients with borderline tuberculoid leprosy, but was delayed in patients with borderline lepromatous leprosy. The plasma from each leprosy patient was also observed to have the same effect on lymphocytes from unrelated individuals, showing that the inhibition and augmentation were due to factors in the plasma and not to a change in lymphocyte receptors. It is possible that the normal stable state of leprosy results from the presence of factors in plasma which act as a control mechanism, and that delayed hypersensitivity reactions may be caused by a breakdown of this control.

Adolescent↗
PubMed1999

[Disabilities observed in new cases of leprosy diagnosed in the Bamako district (Mali) in 1994].

Our study concerns 244 new cases of leprosy diagnosed in the Bamako district in 1994. 154/244 patients could be contacted and were examined in the Leprosy Department of the Marchoux Institute in Bamako. Results showed that the presence of leprosy induced physical disabilities was associated with male gender (59%), advanced age (68%) and multibacillary disease (68%). Disabilities were also more frequent among patients having a rural or manual occupation at the time of screening or afterwards. There was a significant increase (p < 0.001) in the prevalence of disabilities when comparing patients at the time of diagnosis (29%) and thereafter (48%). This means that in 40% of disability cases, lesions developed during or after the treatment. Disabilities were predominantly observed in hands (33%) and feet (29%) with more frequent lesions in lateral popliteal, superior ulnar and posterior tibial nerves. Our results seem to demonstrate the inadequacy of preventive measures and management. This stresses the need for adequate prevention and therapy of leprosy induced disabilities in order to obtain proper eradication of leprosy induced health problems.

Adolescent↗
PubMed2000

The role of Schwann cells, T cells and Mycobacterium leprae in the immunopathogenesis of nerve damage in leprosy.

Damage to peripheral nerves is the major complication of reversal (type I) reactions in leprosy. The underlying mechanism of nerve damage remains largely unresolved; however, an important role for type-1 T cells has been suggested. Mycobacterium leprae has a remarkable tropism for the Schwann cells that surround peripheral axons. Because reversal reactions in leprosy are often accompanied by severe and irreversible nerve destruction, and are associated with increased cellular immune reactivity against M. leprae, a likely immunopathogenic mechanism of damage to Schwann cells and peripheral nerves in leprosy is that infected Schwann cells process and present antigens of M. leprae to antigen-specific, inflammatory, type-1 T cells, and that these T cells subsequently damage and lyse infected Schwann cells. Previous animal studies with CD8+ T cells revealed evidence for the existence of such a mechanism. A similar role has been suggested for CD4+ T cells. These latter cells may be more important in causing nerve damage in vivo, given the predilection of M. leprae for Schwann cells, and the dominant role of CD4+, serine esterase+ Th1 cells in the lesions of leprosy. Antagonism of the molecular interactions among M. leprae, Schwann cells and inflammatory T cells may therefore provide a rational strategy for prevention of damage of Schwann cell and nerves in leprosy.

Female↗
PubMed2000

Single lesion paucibacillary leprosy: baseline profile of the Brazilian Multicenter Cohort Study.

In Brazil, there is little information about the clinical and epidemiological characteristics of paucibacillary, single skin lesion leprosy patients (SSL-PB). Only recently has the official notification system distinguished leprosy patients with a single lesion as a clinical entity, for whom the single-dose ROM (rifampin, ofloxacin and minocycline) regimen has been recommended. In this paper, we describe the baseline clinical features and the immunological background of a multicenter cohort of SSL-PB leprosy cases enrolled between December 1997-1998. Patients were recruited at health centers located in the following regions: Southeast = Rio de Janeiro; North = Amazon and Rondônia states and Center-West = Goiás state. Eligible cases were newly detected, untreated single-lesion leprosy patients without thickened nerve involvement, and were assessed by clinical, bacilloscopic and histopathological exams. The Mitsuda skin test and anti-PGL-I serology (ELISA) were also performed. Of the 299 SSL-PB leprosy patients, 259 (86.6%) fulfilled the criteria for single-dose ROM intervention. Our results showed that patients recruited from different sites had similar features, considering the clinical and immunological profiles. There was a predominance of adults (mean age 32.4; S.D. = 16.0), and a BCG scar was detected in 76.7% of the children (< or = 15 years old). Only 7 cases were diagnosed as the multibacillary type, representing less than 3% of the patients being misclassified. Our data indicate that in Brazil SSL-PB case ascertainment based on clinical and bacilloscopic criteria can be accurately defined under a routine control program; 75.0% of SSL-PB cases were Mitsuda positive (> or = 5 mm) and seropositivity for anti-PGL-I was detected in 17.3% of the patients. These data are compatible with effective cell-mediated immunity and low bacillary load, suggesting favorable clinical outcomes for most SSL-PB participants of this cohort.

Adolescent↗