LEPROSY

Leprosy….
• Leprosy or Hansen’s disease is a chronic infectious disease caused by a bacillus, Mycobacterium
leprae (m leprae), which multiplies slowly and has a long incubation period, on an average, 5-7
years.

• Symptoms may occur within 1 year but can also take as long as 20 years or even more.

• Infection can lead to involvement of the nerves, respiratory tract, skin, and eyes. The nerve
damage may result in a lack of ability to feel touch, pressure, pain, heat and cold, which may lead
to the loss of parts of a person’s extremities from repeated injuries or infection.
Present Global Scenario
• 202,256 new leprosy cases registered globally in 2019, according to official figures from 161
countries (WHO weekly epidemiological record 2020).

• Among the new cases, 10816 new cases were detected with Grade- 2 disabilities (G2D).

• India contributed 57% of the total new cases detected world-wide in the year 2019-20,
comprising of 26% of G2D .cases and 43% of new child cases
Trends of New cases detected, ANCDR and
PR….
Epidemiological Status of since 2005….
• India has achieved the elimination of leprosy as a public health problem i.e., defined as less than 1 case per
10,000 population, at the National level in December 2005.

• Prevalence Rate (PR) at National level was 0.84 per 10,000 population in 2005-06 which has been reduced
to 0.66 per 10,000 population in 2015-16 which further reduced to 0.57 per 10,000 population in 2019-20.

• Prevalence Rate (PR) reduced further to 0.40 and 0.45 per 10,000 population in 2020- 21 and 2021-22
respectively.

• A total of 75,394 new cases were detected during the year 2021-22, which gives Annual New Case
Detection Rate (ANCDR) of 5.09 per 100,000 population. ANCDR was 14.27 per lakh population in 2005-
06.
Epidemiological Status of since 2005….
• In 2009-10, Grade 2 Disability cases among new cases were 4,117 (3.08%) which increased to
5,794 (4.61%) in 2014-15.

• Subsequently with introduction of innovative activities in the programme, good results were
observed in declining of the G2D cases and G2D% among new cases i.e., 5245 (3.87%), 4552
(3.61%) and 3666 (3.05%) in 2016-17, 2017-18 and 2018-19 respectively.
Sustainable Development Goal (SDG)
pertaining to Health….
• SDG target 3.3, which calls to “end the epidemics of AIDS, tuberculosis, malaria and neglected
tropical diseases (NTDs) and combat hepatitis, water-borne diseases and other communicable
diseases” by 2030, as part of Goal 3 (Ensure healthy lives and ensure well-being for all at all ages)
which includes the attainment of leprosy elimination.
Diagnosis of Leprosy
• At least one of the following cardinal (unique and very important) signs must be present to
diagnose leprosy.

a) Hypo-pigmented or reddish skin lesion(s) with definite sensory deficit;

b) Involvement of the peripheral nerves, as demonstrated by definite thickening with loss of

sensation and weakness /paralysis of the corresponding muscles of the hands, feet, or eyes;

c) Demonstration of M leprae in the lesions.

Case of Leprosy: A person with at least one cardinal sign of leprosy and yet to
complete a full course of MDT may be called a “case of leprosy.”
Skin examination.
• The following features must be noted when examining a patch on the skin.

• Number: The number of lesions indicates the severity of the disease. This is useful for
leprosy disease classification.

• Colour: May be hypo-pigmented (lighter in colour than the rest of the skin), or
erythematous (red), raised/swollen. Lesions of leprosy are never de-pigmented.

• Sensory deficit: This is useful for diagnosis. Loss of sensation is a cardinal sign of
leprosy.
• Tenderness on gentle tapping.

• Presence of infiltration: skin which is thickened, shiny, and erythematous. All three features must
be present in the same area.
Nerve examination:
• "Involvement of the peripheral nerves, as demonstrated by definite thickening with a loss of
sensation with or without weakness /paralysis of the corresponding muscles of the hands, feet or
eyes"
Assessment of Nerves Function:
• Voluntary Muscle Testing (VMT): Voluntary muscle testing is done by first checking the range of
movement to see whether movement is normal, reduced, or absent due to paralysis. If
movement is normal, a resistance test is then done.

• S (Strong) = Able to perform the movement against full resistance; W (Weak) = Able
to perform the movement but not against full resistance; P (Paralysed) = Not able
to perform the movement at all.
Sensory Test (S.T.)-The method of sensory test over the skin supplied by the nerve is the
same as that for testing a patch. Below are the suggested spots for testing sensation over
the palms and soles.
Disease Classification:
• Criteria for classification.
Grading Of Disabilities
• Hands and Feet Grade

• 0: No anesthesia over palm/sole, No visible deformity or damage

• Grade 1: Anaesthesia present over palm/sole but no visible deformity or damage;

weakness/paralysis but no visible deformity

• Grade 2: Visible deformity or damage present

• Eyes

• Grade 0: No eye problem due to leprosy; no evidence of visual loss

• Grade 2: Severe visual impairment (vision worse than 6/60; inability to count fingers at six meters),
lagophthalmos, iridocyclitis, and corneal opacities.
Management of Leprosy….
• The treatment of leprosy is Multi Drug Therapy (MDT) which is the combination of two or
three of the following drugs:

• a) Cap. Rifampicin b) Tab. Dapsone c) Cap. Clofazimine

• i. MDT kills the bacilli (M. leprae) in the body and thus stops the progression of the
disease and prevents further complications.

• ii.As the M. leprae are killed, the patient becomes non-infectious and thus the spread of
infection is reduced.
The Appropriate dose for children under 10 year of age can be decided on the basis of body weight
• Rifampicin: 10 mg/kg/month • Clofazimine: 6 mg/kg/month and 1 mg/kg/day (to be given weekly
capsule as the lowest available dose is 50mg) • Dapsone: 2 mg/kg/day
Lepra Reactions, Neuritis and its
Management
• Type I Lepra Reaction This may be the first presenting sign of the disease. It usually
lasts for a few weeks to a few months but in some patients, can be recurrent. It presents
with inflammation of existing skin lesions.

• Inflammation of skin lesions: Signs of inflammation are seen in the existing skin lesions
i.e. skin lesions become red, more prominent, swollen, shiny, and warm. In severe
forms, they may ulcerate.

• Inflammation of nerves: Nerves are frequently affected in Type 1 Reaction.

Lepra Reactions, Neuritis and its
Management
• Swelling of hands and feet: Swelling of the limbs and/or face may be part of Reaction.

• Eyes: Ocular tissue is not affected in Type 1 Reaction, but a patient may develop
corneal anesthesia and lagophthalmos due to the involvement of trigeminal and facial
nerves.
Type 2 Lepra Reaction
• Type 2 Lepra Reaction: Occurs in patients with a high bacillary load. It is a vasculitis
due to the precipitation of immune complexes in multiple organ systems (skin, nerves,
testes, eyes, joints, lymph nodes, kidneys, liver, spleen, bone marrow). It may be the
presenting disease complaint and usually lasts for a few weeks to several months.
Type 2 Lepra Reaction
• Skin lesions: Type 2 Reaction exhibits the typical signs of erythema nodosum - red, firm,
painful, tender, subcutaneous nodules (about 1-2 cm across) of variable size
appearing in crops.

• Nodules blanch on pressure.

• Usually multiple, they tend to be distributed bilaterally and symmetrically. They appear
preferentially on cooler parts of the skin. They usually spare the warmer parts of the body,
like the hairy scalp, axilla, groin, and perineum.

• Rarely they can break down and suppurate/necrose-producing Erythema Nodosum

Necroticans (ulcerative ENL).
Type 2 Lepra Reaction
• Eyes: Ocular tissue may get affected. This may lead to iritis/iridocyclitis (inflammation of
the iris and ciliary body), synechiae, glaucoma and impairment of vision.

• Eye becomes red, watery, and painful; pupil constricted and nonreactive.

• Swelling of hands, feet, and face may occur.

Type 1 Lepra reaction
• Symbolizes beauty and purity in lotus:
• Leprosy can be cured and a leprosy patient can be a
useful member of society in the form of a partially
affected thumb; a normal fore-finger and the shape of a
house;
• The symbol of hope and optimism in a rising sun.
Sustainable Development Goal (SDG)
pertaining to Health….
• SDG target 3.3, which calls to “end the epidemics of AIDS, tuberculosis, malaria and neglected
tropical diseases (NTDs) and combat hepatitis, water-borne diseases and other communicable
diseases” by 2030, as part of Goal 3 (Ensure healthy lives and ensure well-being for all at all ages)
which includes the attainment of leprosy elimination.
WHO NTD Roadmap 2030….
• The WHO has unveiled a NTD roadmap of 2021 to 2030. The NTDs prioritized by WHO are a
diverse set of 20 diseases including leprosy with a singular commonality: their devastating impact
on impoverished communities, living predominantly in tropical and subtropical areas.
Global Leprosy Strategy 2021–2030
• Move towards multi disease service integration, digitalization and accountability, and addresses
key challenges, such as human resource capacity, surveillance and antimicrobial resistance.

• Interruption of transmission in a country or a subnational area is defined as no local transmission of

M. leprae, evidenced by zero occurrence of new indigenous (autochthonous) cases among
children ≤15 years for at least 5 consecutive years.

• Elimination of leprosy is achieved when a country or a sub-national area reports zero new
indigenous leprosy cases for at least 3 consecutive years after interruption of transmission.

• After elimination has been verified by WHO, the country begins post-elimination surveillance for
≥10 years
WHO 2030 Target, Sub-Targets and
Milestones
Historical Background….
• The National Leprosy Control Programme (NLCP) was launched in 1955.

• Multi Drug Therapy (MDT) for leprosy was introduced and the NLCP was renamed as National Leprosy Eradication
Programme (NLEP) in 1983 and implemented as a Centrally Sponsored Scheme which significantly accelerated the
elimination of leprosy as a public health problem.

• As India stepped into the new millennium, the prevalence rate of leprosy was 3.7 per 10,000 in March 2001

• The country adopted the strategy of decentralization of the leprosy programme to States and Union Territories and
integration of leprosy into the general health care services.

• In 2005, India achieved the goal set by the National Health Policy, 2002 of elimination of leprosy as a public health
problem, defined as less than 1 case per 10,000 population at the national level. However, prevalence rate
remained above 1 per 10,000 population in several districts and blocks and new cases continued to occur.
Rationale behind NSP and Roadmap 2023-
2027
 Delay in detection on account of low awareness, pandemic, and other health emergencies.

 Increasing Human Resource under new programmes requiring training.

 Limited laboratory services and diagnostic tool.

 Coordination with partners and stakeholders is still limited.

 Need for strengthening resistance to first-line drugs and expansion of AMR surveillance especially as post-
exposure prophylaxis is scaled up.

 Paper based reporting system.

 Migration and Urbanization.

 Stigma and discrimination are deeply embedded in many communities.

National Strategic Plan and Roadmap for
Leprosy 2023-2027…..
• Vision: Leprosy free India with zero infection and disease, zero disability, zero stigma and
discrimination.

• Goal: Accelerate towards achieving Interruption of Leprosy Transmission in India.

Specific objectives:
 Strengthen leadership, commitment, and partnerships

 Acceleration of Case Detection

 Provision of Quality Services

 Enhanced measures for Prevention of Disease, Disabilities, Stigma, Discrimination and Violation
of Human Rights

 Digitalization of Surveillance Systems

The Road map….
THANK YOU