LEPROSY AND LEPROSY PROGRAM

The History of Leprosy

 Evidence of leprosy has been found in ancient skeletons from the Near East and it was probably present in Western Europe more than 200 years ago. It became a common disease in Europe in medieval times. The disease died out in most of Europe for reasons which are not clear, more than 200 years ago, although there were significant numbers of new cases in Norway until the early years of the 20th century. UNESCO's Memory of the World has extensive archived material from this welldocumented epidemic in Norway. An online database of material on the History of Leprosyis available, although unfortunately few of the resources listed in the databases are themselves online. The severe stigma attached to leprosy usually meant that people affected were driven into segregated settlements know as "leper colonies". Fortunately, most of these have either been closed or developed into normal communities.

 Leprosy existed in the Philippines long

before the arrival of the Spanish in the 16th century and was known locally by such terms as 'ketong' and 'cizaro'.  In the early 1900s, there was a fairly high incidence of leprosy in the Philippines. The American colonial administration was keen to implement health and sanitation programmes, influenced by popular fields of public health and tropical medicine .

 Given the absence of any known cure and

inspired by numerous positive reports about the colony in Molokai in Hawaii, an active campaign for the segregation of lepers was initiated. One such leper colony was located on Culion Island and opened in 1906. In order to provide a legal framework for the active collection and incarceration of people suspected of leprosy throughout the archipelago, a segregation law, that practically criminalized the harbouring and non-voluntary submission of lepers , was enacted in 1907. At its peak, Culion was home to over 5,000 people.

 When the Philippines National Leprosy

Control Program (NLCP) was established in 1986, there were 38,570 registered leprosy patients in the country. According to WHO statistics, there were 2, 514 new cases detected in 2007.

What is Leprosy?
 Leprosy (also known as Hansen s Disease) is a chronic, infectious disease involving the skin and nerves of infected individuals. Pale patches on the skin are usually the first sign of the disease they are painless and do not itch, so are often ignored by the patient.

 In the past, nerve damage and other complications occurred as the disease progressed. The numbness and lack of feeling in the limbs often led to festering wounds on the hands and feet, and then to the characteristic deformities of the face and limbs. In many communities this led to stigma towards those affected and their families, causing them to be shunned and even excluded from everyday life.

 Fortunately, antibiotics can now quickly kill

the bacteria (germs) that cause leprosy, so the disease can be completely cured with a few months of treatment. If this is started at an early stage, most patients need never suffer the terrible complications which used to be common. Nerve damage does still occur in some patients, but it can often be reversed with other medical treatment. When it cannot be reversed and the person remains with some disability, there are many different strategies of rehabilitation to help them live as normal a life as possible.

How do you catch leprosy?

 Leprosy is probably spread like the

common cold, but is much less contagious than the cold, or influenza. You really have to live for some years in an endemic area, where new cases of leprosy are continually being detected, to run the risk of catching it. In a study of new cases being put on treatment in the United Kingdom, it was found that all of them had lived abroad in a country with leprosy for at least eight years.

Transmission and Control of Leprosy

 Leprosy is caused by a bacterium,

Mycobacterium leprae, which is closely related to the organism causing tuberculosis. The mechanism of infection is not fully understood, but it is generally thought to be by droplet spread through the upper respiratory tract. The incubation period is long, usually between 2 and 8 years, but it can be up to 20 years in some cases.

 Casual contact with a person affected by leprosy

does not seem to lead to infection. The evidence suggests that residence for several years in an endemic area is needed before the risk of infection becomes appreciable. The current strategy to control leprosy involves early case finding and treatment with antibiotics, with the aim of stopping transmission of the disease to new contacts.  WHO gives an overview of leprosy and leprosy control activities around the world. ILEP Member Associations support leprosy activities on a countryby-country basis throughout the world. In the USA, the Center for Disease Control (CDC) , gives general information about leprosy. The Report of the ILA Technical Forum (394KB), held in Paris in 2002, reviews much of the scientific evidence underpinning current efforts to control leprosy.

The Diagnosis of Leprosy

 Leprosy is essentially a clinical diagnosis,

although a laboratory test (the slit skin smear) is important in some cases. Normally, the diagnosis rests on finding any one of three cardinal signs, one or more hypopigmented, anaesthetic skin patches, typical of leprosy; one or more thickened peripheral nerves; or a positive skin smear.

 WHO emphasizes the first of these signs for use

by junior health workers in endemic areas and gives a clear description of how to examine the skin.  As with many diseases, the most accurate diagnostic test is a biopsy, with subsequent staining and histopathologicalexamination of the tissues.  One major topic for research at present, is the development of new diagnostic tests, which may allow leprosy to be diagnosed with confidence at a much earlier stage; this would mean that treatment could begin early, resulting in less disability and probably also in less transmission of the disease to contacts.

The Classification of Leprosy Cases

 Leprosy exhibits quite a wide range of

clinical features in different people and this is now thought to be due to differences in the body's immune response to the infection. Most people have an effective response which completely prevents the disease, while others have only a moderate response which allows the disease to appear, but limits it to only a few skin patches.

 In these patients, the number of leprosy bacilli in

the body is quite small (less than a million) and they don't show up on the skin smear test, which is negative; the disease is classified as paucibacillary (meaning 'few bacilli'). A very small minority of people, on the other hand, have such a weak immune response to the leprosy bacillus that it can multiply almost without any check and spread to almost all parts of the skin and the peripheral nerves.  In these patients the skin smear is positive and the disease is classified as multibacillary (meaning 'many bacilli').

 For the purposes of treatment, all patients are

put into one category or the other (either paucibacillary - PB - or multibacillary - MB), but this is somewhat arbitrary. The disease should be seen as a more or less continuous spectrum from high to low immunity. It should be pointed out that people who get multibacillary leprosy have no other immune deficiencies and have no particular susceptibility to any other disease.  The straightforward classification of leprosy into two treatment groups (PB/MB)is described by WHO. The older, but more detailed, classification of leprosy is known as the Ridley/Joplingclassification.

The Treatment of Leprosy

 As a bacterial infection, leprosy can be very effectively treated with certain antibiotics; the bacillus can be easily killed. If there has already been damage to the nerves, however, antibiotics alone will not restore function and other forms of treatment will be needed, including physiotherapy.

 The first antibiotic to be widely used for leprosy

was dapsone, from around 1950 onwards. Dapsone meant a major breakthrough for millions of patients who, until then, had been considered incurable. However, many patients still had to take medicines for life.  In 1981, when resistance to dapsone was becoming widespread, WHO introduced MultiDrug Therapy (MDT)which consisted of two regimens: rifampicin and dapsone for PB leprosy and rifampicin , clofazimine and dapsonefor MB leprosy. (Note: rifampicin is also known as rifampin, especially in the USA). MDT has been remarkably successful: there have been very few side effects associated with its use and over 13 million people have been cured of leprosy following its introduction.

Prevention of Disability
 Nerve involvement starts quite early in a few

cases, but in others occurs only late in the disease, especially if it is left untreated. It commonly leads to weakness of various muscles and loss of sensation in the hands and feet, so that the person no longer feels hot or cold, or even pain - this leads to unintentional damage, ulceration, infection and eventual destruction of fingers and toes, and the well-known deformities of untreated leprosy.

 The muscles around the eye may also be

affected and blindness is another important complication of untreated disease. Efforts to prevent disability in people who already have some nerve damage due to leprosy therefore concentrate particularly on the eyes, hands and feet.  Fortunately, the complications of leprosy, such as nerve involvement and eye damage, can themselves be treated, so that the problem may sometimes be reversed completely, or, if that is no longer possible, further deterioration can be prevented. As may be expected, more severe damage requires more complex and lengthy treatment, and is more likely to leave some residual disability or deformity.

Rehabilitation
 Some people who get leprosy are unfortunately left with some residual disabilities after the infection itself has been cured. The eyes, hands and feet are the parts commonly affected. In addition, many also face long-term problems within their family and community, simply because they once had leprosy.

 Rehabilitation involves a whole range of

interventions that attempt to restore the person affected to as normal a life as possible.  There are two major categories of rehabilitation: 1. Firstly, physical rehabilitation seeks to help people with their normal daily activities; the methods include physiotherapy and occupational therapy, and sometimes specialized forms of reconstructive surgery to improve the functioning of the hands or feet; special treatment of certain eye problems may also be possible. The aim is to help with the physical demands of daily life.

2. The second major category is socio-economic rehabilitation, which seeks to help people rebuild their lives, including their relationships and household economies, both of which are often severely disrupted by having leprosy.  Many people with leprosy face the loss of their jobs and divorce or other forms of rejection by society. Rehabilitation involves informing and reassuring the families and communities of the facts about leprosy, as well as developing specific interventions that help to restore dignity to those affected. One of the major aims is to empower individuals, enabling them to have more control over their own situations.

The International Classification of Functioning Health

 This WHO program has attempted, with

considerable success, to standardize the terminologyused in relation to health and disability. The ICF uses a conceptual framework for long term consequences of health conditions that is very helpful in the case of POD and rehabilitation of people affected by leprosy.

Immunology
 As already mentioned, the body's immune

response to infection with M leprae is the most important factor determining the outcome of the disease in any individual patient. This is a complex field which is continuously changing as new findings modify older hypotheses.

 Leprosy Control Program envisions to eliminate Leprosy

as a human disease by 2020 and is committed to eliminate leprosy as a public health problem by attaining a national prevalence rate (PR) of less than 1 per 10,000 population by year 2000. Its elimination goals are: reduce the national PR of <1 case per 10,000 population by year 1998 and reduce the sub-national PR to <1 case per 10,000 population by year 2000. Kilatis Kutis Campaign.  Program thrust is towards finding hidden cases of leprosy and put them on Multi-Drug Therapy (MDT), emphasizing the completion of treatment within the WHO prescribed duration.  Strategies are case-finding, treatment, advocacy, rehabilitation, manpower development and evaluation.