1. UNIVERSITY OF MEDICAL SCIENCES
AND TECHNOLOGY
LEPROSY
(Hansen's disease)
Presented by;
Dr.AlteibYousif
Dec 2012
12/16/20129:55 AMDr. Alteib

2. CONTENT
 History and background
 Key facts
 Types of leprosy
 Risk factors
 Signs and symptoms
 Complications
 Diagnosis
 Treatment and prevention
 Global current situation
 Situation in Sudan
 Elimination of leprosy
12/16/20129:55 AMDr. Alteib

3. HISTORY & BACKGROUND
 Leprosy was recognized
in the ancient civilizations of
China, Egypt and India.
 The earliest documented
account of leprosy is around 1550
B.C on Egyptian papyrus.
 Throughout history, the badly
affected have often been hated
by their communities and families (stigmatization).
12/16/20129:55 AMDr. Alteib

4. Con..
 Although leprosy was
treated differently in the
past, the first advance in
treatment occurred in the
1940s with development
of the drug Dapsone,
which arrested the disease.
But duration of the treatment
was many years, even a lifetime, making it difficult for
patients to follow.
12/16/20129:55 AMDr. Alteib

5. Con..
 In the 1960s, M. leprae started to
develop resistance to Dapsone, the
world’s only known anti-leprosy drug
at that time.
 In the early 1960s, Rifampicin and
Clofazimine, the other two
components of recommended
multidrug therapy (MDT), were
discovered.
12/16/20129:55 AMDr. Alteib

6. Con..
 In 1981,WHO Study Group
recommended MDT.
 Since 1995,WHO provides free MDT for
all patients in the world, initially through
the drug fund provided by the Nippon
Foundation and since 2000, through the
MDT donation provided by Novartis and
the Novartis Foundation for Sustainable
Development.
12/16/20129:55 AMDr. Alteib

7. KEY FACTS
 Leprosy is a chronic infectious disease caused
by an acid-fast, rod-shaped
bacillus, Mycobacterium leprae.
 Official figures show that almost 182 000
people, mainly in Asia and Africa, were
affected at the beginning of 2012, with
approximately 219 000 new cases reported
during 2011.
12/16/20129:55 AMDr. Alteib

8. Con..
 M. leprae multiplies very slowly and the
incubation period of the disease is about five
years.
 Symptoms can take as long as 20 years to
appear.
 Leprosy is not highly infectious.
 Leprosy is transmitted via droplets, from the
nose and mouth, during close and frequent
contacts with untreated cases.
12/16/20129:55 AMDr. Alteib

9. Con..
 Untreated, leprosy can cause progressive and
permanent damage to the skin, nerves, limbs
and eyes.
 The disease mainly affects the skin, the
peripheral nerves, mucosa of the upper
respiratory tract and also the eyes.
 Leprosy is curable and treatment provided in
the early stages averts disability.
12/16/20129:55 AMDr. Alteib

10. RISK FACTORS FOR LEPROSY
 People who live in the areas where leprosy is
endemic (parts of India, China, Japan, Nepal,
Egypt, and other areas) and especially those
people in constant physical contact with infected
people.
 There is some evidence that genetic defects in
the immune system may cause certain people to
be more likely to become infected (region q25 on
chromosome 6).
 People who handle certain animals that are
known to carry the bacteria (armadillos,
chimpanzee,…) are at risk of getting the bacteria
from the animals
12/16/20129:55 AMDr. Alteib

11. CLASSIFICATION OF LEPROSY
Two types of classifications:
 Skin smear result classification
 Clinical classification
12/16/20129:55 AMDr. Alteib

12. Con..
SKIN SMEAR RESULTS CLASSIFICATION
1. Paucibacillary leprosy (PB) – few Bacilli;
Two to five skin lesions with negative skin
smear results at all sites
2. Multibacillary leprosy (MB);
Any form of leprosy in which the patient shows
positive smears at any site
12/16/20129:55 AMDr. Alteib

13. Con..
CLINICALCLASSIFICATION
1. Indeterminate leprosy (IL)
2.Tuberculoid leprosy (TT)
3. Lepromatous leprosy (LL)
4. Borderline leprosy (BL):
Borderline tuberculoid leprosy (BT)
Borderline borderline leprosy (BB)
Borderline lepromatous leprosy (BL)
12/16/20129:55 AMDr. Alteib

14. Con..
Adapted from Ramos-e-Silva M , Castro MCR. Mycobacterial infections.
In: Bolognia JL; Jorizzo JL; Rapini RP. Dermatology. 2nd edition. London: Mosby, 2008; 1109.
12/16/20129:55 AMDr. Alteib
CLASSIFICATION OF LEPROSY
Clinical findings Lepromatous Leprosy Borderline Leprosy Tuberculoid leprosy Indeterminate
leprosy
Type of lesions Macules, papules, nodules,
diffuse infiltration
Macules, papules,
plaques, infiltration
Infiltrated plaques,
oftenhypopigmented
Macules,
oftenhypopigmented
Number Numerous Many One or few (up to 5)
lesions
One or few
Distribution Symmetric Tendency to symmetry Localized,
asymmetric
Variable
Definition Vague, difficult to distinguish
normal versus affected skin
Less well- defined
borders
Well-defined, sharp
borders
Not always defined
Sensation Not affected Diminished Absent Impaired
Bacilli in skin
lesions
Many (globi) Many None detected Usually none
detected
Adapted from Ramos-e-Silva M , Castro MCR. Mycobacterial infections.In: Bolognia JL; Jorizzo JL; Rapini RP. Dermatology. 2nd edition. London: Mosby, 2008; 1109.

15. SIGNS AND SYMPTOMS
Tuberculoid leprosy:
Early signs and symptoms
of Tuberculoid leprosy can
include one or more slight
red patches of skin that
appear on the trunk or
extremities.
12/16/20129:55 AMDr. Alteib

16. Con..
Other signs and symptoms of
Tuberculoid leprosy include:
• Skin stiffness and dryness
• Loss of fingers and toes
• Eye problems, which leads
to blindness
• Severe pain
• Muscle weakness, especially
in the hands and feet
• Enlarged nerves, especially
• those around the elbow and knee.
12/16/20129:55 AMDr. Alteib

17. Loss of eyebrows and eyelashes
12/16/20129:55 AMDr. Alteib

18. 12/16/20129:55 AMDr. Alteib
Hypopigmented Macule
inTuberculoid Leprosy
Nose Deformity BorderlineTuberculoid
Leprosy Skin Lesion

19. Con..
 It is important to note that not all people with
leprosy lose their fingers and toes. With early
diagnosis and treatment, many of these signs
and symptoms of leprosy can be prevented.
 Many patients with Tuberculoid disease can
even self-heal without benefit of treatment.
 In order to prevent problems with fingers or
toes, people should avoid injury and infections
to these areas and take their medicines as
prescribed.
12/16/20129:55 AMDr. Alteib

20. Con..
Lepromatous leprosy:
It is the severe form of
leprosy, signs and
symptoms can Include
a symmetrical skin rash
More commonly found on:
 Elbows
 Knees
 Buttocks
 Face
 Ears
 Wrists.
12/16/20129:55 AMDr. Alteib

21. arm nodules in lepromatous leprosy
12/16/20129:55 AMDr. Alteib

22. Con..
Other signs and symptoms
of Lepromatous leprosy:
• Thinning of eyebrows
and eyelashes
• Thickened skin on face
• Nasal stuffiness
• Bloody nose
• Laryngitis
• Collapsing of the nose
12/16/20129:55 AMDr. Alteib

23. Con..
• Swelling of the lymph nodes in the
groin and armpits
• Scarring of the testes that leads to
infertility
• Enlargement of male breasts.
12/16/20129:55 AMDr. Alteib

24. ASSOCIATED COMPLICATIONS
 Leprosy is probably
the most common cause
of crippling in the hands
worldwide.
 Leprosy complications
can include:
Blindness
Loss of fingers or toes
following an injury or infection
12/16/20129:55 AMDr. Alteib

25. DIAGNOSIS
 Diagnosis of leprosy is most
commonly based on the clinical signs
and symptoms. These are easy to
observe by any health worker after a
short period of training.
 Only in rare instances there is a need
to use laboratory and other
investigations to confirm a diagnosis
of leprosy.
12/16/20129:55 AMDr. Alteib

26. Con..
 In an endemic country or area, an
individual should be regarded as
having leprosy if he or she shows
ONE of the following cardinal signs:
 skin lesion consistent with leprosy
and with definite sensory loss, with
or without thickened nerves
 positive skin smears
12/16/20129:55 AMDr. Alteib

27. TREATMENT
Multidrug therapy (MDT)
treatment has been made
available byWHO free of
charge to all patients
worldwide since 1995,
and provides a simple
yet highly effective cure
for all types of leprosy.
12/16/20129:55 AMDr. Alteib

28. Con..
 The drugs used inWHO-MDT are a
combination of:
 Among these Rifampicin is the most
important anti leprosy drug and therefore is
included in the treatment of both types of
leprosy.
12/16/20129:55 AMDr. Alteib
Multi Bacillary (MB) leprosy Paucibacillary (PB)
leprosy
Rifampicin + Clofazimine + Dapsone Rifampicin + Dapsone

29. WHO recommended MDT regimens
12/16/20129:55 AMDr. Alteib
Multibacillary (MB) Paucibacillary (PB) Single Skin Lesion (PB)
Adults:
Rifampicin: 600 mg/m
Dapsone: 100 mg/d
Clofazimine:300mg/m+50mg/d
Adults:
Rifampicin: 600mg/m
Dapsone: 100mg/d
Adults:
Rifampicin: 600 mg
Ofloxacin: 400 mg
Minocycline:100mg
Children 10-14 years:
Rifampicin: 450mg/m
Dapsone: 50 mg/d
Clofazimine: 150mg/m & 50mg/d
Children 10-14 years:
Rifampicin: 450mg/m
Dapsone: 50mg/d
Children 10-14 years:
Rifampicin: 300 mg
Ofloxacin: 200 mg
Minocycline: 50 mg
Children less than 10:
Rifampicin: 300mg/m
Dapsone: 25 mg/d
Clofazimine: 100 mg/m & 50mg
twice/w
Children less than 10:
Rifampicin: 300mg/m
Dapsone: 25 mg/d
Children less than 10:
Not recommended for
pregnant women
and children < 5 yrs
Duration= 12 months Duration= six months Duration= once

30. Con..
12/16/20129:55 AMDr. Alteib

31. Con..
 Treatment of leprosy with only one anti leprosy
drug will always result in development of drug
resistance to that drug.
 Treatment with Dapsone or any other anti
leprosy drug used as mono therapy should be
considered as unethical practice.
12/16/20129:55 AMDr. Alteib

32. Con..
 The role for surgery in the treatment of leprosy
occurs after medical treatment (antibiotics) has
been completed with negative skin smears (no
detectable acid-fast bacilli) and is often only
needed in advanced cases.
 Surgery is individualized for each patient with
the goal to attempt cosmetic improvements
and, if possible, to restore limb function and
some neural functions that were lost to the
disease.
12/16/20129:55 AMDr. Alteib

33. PREVENTION
 Prevention of contact with droplets from
nasal and other secretions from patients with
untreated M. leprae infection.
 Treatment of patients with appropriate
antibiotics stops the person from spreading
the disease.
 People who live with individuals who have
untreated leprosy are about eight times as
likely to develop the disease, because they
have close proximity to infectious droplets.
12/16/20129:55 AMDr. Alteib

34. Con..
 Leprosy is not hereditary, but recent findings
suggest susceptibility to the disease may
have a genetic basis.
 There is no commercially available vaccine
available to prevent leprosy. However, there
are reports of using BCG vaccine, the BCG
vaccine along with heat-killed M. leprae
organisms.
12/16/20129:55 AMDr. Alteib

35. PROGNOSIS
 The prognosis of leprosy varies with the stage of
the disease when first diagnosed and treated.
 Early diagnosis and treatment limits or prevents
tissue damage so the person has a good
outcome.
 However, if the patient's disease has progressed
to more advanced disease, the complications can
markedly affect the patient's lifestyle, and thus
the condition has a fair to poor prognosis.
12/16/20129:55 AMDr. Alteib

36. GLOBAL CURRENT SITUATION
 Leprosy control has improved significantly
due to national and sub-national campaigns
in most endemic countries.
 Integration of primary leprosy services into
existing general health services has made
diagnosis and treatment of the disease easy.
12/16/20129:55 AMDr. Alteib

37. Con..
 The implementation of the global leprosy
strategy 2011–2015 national leprosy
programs now focus more on underserved
populations and inaccessible areas to
improve access and coverage.
 Since control strategies are limited, national
programs actively improve case holding,
contact tracing, monitoring, referrals and
record management.
12/16/20129:55 AMDr. Alteib

38. Con..
 According to official reports received from
105 countries and territories, the global
registered prevalence of leprosy at the
beginning of 2012 stood at 181 941 cases.
 The number of cases detected during 2011
was 219 075 compared with 228 474 in 2010.
12/16/20129:55 AMDr. Alteib

39. Con..
 Pockets of high endemicity still remain in
some areas of Brazil, Indonesia, Philippines,
Democratic Republic of Congo, India,
Madagascar, Mozambique, Nepal, and the
United Republic ofTanzania.
 All endemic countries remain highly
committed to eliminating the disease, and
continue to intensify their leprosy control
activities.
12/16/20129:55 AMDr. Alteib

40. SITUATION IN SUDAN
 In 2002 theWHO launched a leprosy control
program, with rapid simple diagnostic tools
and the delivery of multi-drug therapy (MDT).
 All efforts are constrained by instability, lack
of suitable logistics, climate difficulties and
poor roads, lack of resources and changes in
health personnel.
12/16/20129:55 AMDr. Alteib

41. Con.. SITUATION IN SUDAN
 In Northern Sudan 725 cases of leprosy were
detected in 2008, 553 of which were multi
bacillary (MB).
 The cure rate for Multi Bacillary cases was
69.5%. However, in the Kordofan and Darfur
states the Multi Bacillary cure rate was 57.3%
due to instability, population movement and
great stigma.
 In Khartoum the Multi Bacillary cure rate is
80.7%, which percentage is affected by
defaulters, re-registered patients and stigma.
12/16/20129:55 AMDr. Alteib

42. Con.. SITUATION IN SUDAN
Number of new cases in Sudan detected
annually since 2004
12/16/20129:55 AMDr. Alteib
2004 2005 2006 2007 2008 2009 2010 2011
722 720 884 1706 1901 2100 2394 706
Sudan (North & South) pre-
peace agreement
Sudan (North & South) / post-peace
agreement
Sudan (North) / post
separation

43. ELIMINATION OF LEPROSY
 In 1991WHO's governing body, theWorld
Health Assembly (WHA) passed a resolution
to eliminate leprosy by the year 2000.
 Elimination of leprosy is defined as a
prevalence rate of less than 1 case per 10 000
persons.
 The target was achieved on time and the
widespread use of MDT reduced the disease
burden dramatically.
12/16/20129:55 AMDr. Alteib

44. Con..
 Over the past 20 years, more than 14 million
leprosy patients have been cured, about 4
million since 2000.
 The prevalence rate of the disease has
dropped by 90% – from 21.1 per 10 000
inhabitants to less than 1 per 10 000
inhabitants in 2000.
12/16/20129:55 AMDr. Alteib

45. Con..
 Dramatic decrease in the global disease
burden: from 5.2 million in 1985 to 805 000 in
1995 to 753 000 at the end of 1999 to 181 941
cases at the end of 2011.
 Leprosy has been eliminated from 119
countries out of 122 countries where the
disease was considered as a public health
problem in 1985.
12/16/20129:55 AMDr. Alteib

46. Con..
 So far, there has been no resistance to
antileprosy treatment when used as MDT.
 Efforts currently focus on eliminating leprosy
at a national level in the remaining endemic
countries and at a sub-national level from the
others.
 Early diagnosis and treatment with multidrug
therapy (MDT) remain the key elements in
eliminating the disease as a public health
concern.
12/16/20129:55 AMDr. Alteib

47. Con...
WHO STRATEGY FOR LEPROSY ELIMINATION
Components:
ensuring accessible and uninterrupted MDT
services available to all patients through flexible
and patient-friendly drug delivery systems
ensuring the sustainability of MDT services by
integrating leprosy services into the general
health services and building the ability of
general health workers to treat leprosy
12/16/20129:55 AMDr. Alteib

48. Con..
Encouraging self-reporting and early
treatment by promoting community
awareness and changing the image of leprosy
Monitoring the performance of MDT services,
the quality of patients’ care and the progress
being made towards elimination through
national disease surveillance systems.
12/16/20129:55 AMDr. Alteib

49. Con..
 Sustained and committed efforts by the
national programs along with the continued
support from national and international
partners have led to a decline in the global
burden of leprosy.
 Increased empowerment of people affected
by the disease, together with their greater
involvement in services and community, will
bring us closer to a world without leprosy.
12/16/20129:55 AMDr. Alteib

50. Con..
ACTIONSAND RESOURCES REQUIRED:
 In order to reach all patients, leprosy
treatment needs to be fully integrated into
general health services.
 Moreover, political commitment needs to be
sustained in countries where leprosy remains
a public health problem.
 Partners in leprosy elimination also need to
continue to ensure that human and financial
resources are available.
12/16/20129:55 AMDr. Alteib

51. Con..
 The age-old stigma associated with the
disease remains an obstacle to self-reporting
and early treatment.
 The image of leprosy has to be changed at
the global, national and local levels.
 A new environment, in which patients will not
hesitate to come forward for diagnosis and
treatment at any health facility, must be
created.
12/16/20129:55 AMDr. Alteib

52. REFERENCES
 www.who.int/mediacentre/factsheets/fs101/en/index.html
 WHO;Global leprosy situation, 2012
 WHO;Weekly epidemiological record
 OXFORD HAND BOOK OF CLINICA MEDICINE
 DermatologyOnline Journal –Volume 9 - Number 2 /
Department of Bioregulation, Leprosy Research Center,
National Institute of Infectious Diseases, Higashimurayama,
Tokyo, JAPAN, norishii@nih.go.jp
12/16/20129:55 AMDr. Alteib

53. THANKS
AND
ALLTHE BEST
12/16/20129:55 AMDr. Alteib