Hansen's

Disease:
Leprosy
JULIAN | MIGALLEN
 Definition of terms
● Chemoprophylaxis - refers to the administration of a drug to prevent the
development of a disease
● Household Contact - refers to any person who has had direct contact or exposure
with a leprosy case and has been living in the same household with leprosy case for
more than 30 days in the past 2 years
● Index Case - refers to a person who is on active treatment for leprosy Multi drug
therapy (MDT) or those who have received or finished MDT treatment (RFT -
Release from Treatment), Post - Dapsone Monotherapy, or have been declared
cured or negative for a certain period
● Information System (IS) - refers to a database evolved for the purpose of providing
information support for decision-making process. The system is used to analyze data
and generate knowledge-that is useful information in facilitating strategic and
operational activities
● Leprosy Elimination - refers to reduction in the prevalence of registered leprosy
cases to below 1 case per 10,000 populations
● Zero Transmission - refers to the total disappearance of the disease causing
organism
● Leprosy case - refers to a patient infected with Mycobacterium leprae needing treatment
or presently under Multi drug therapy treatment
● Multi-Drug Therapy (MDT) - refers to a regimen made up of a combination of three (3)
drugs for both Multibacillary (MB) and Paucibacillary (PB) leprosy patients with difference
only in duration
● Multibacillary or MB leprosy - refers to a case of leprosy with more than five skin
lesions; or with nerve involvement (pure neuritis, or any number of skin lesions and
neuritis); or with the demonstrated presence of bacilli in a slit-skin smear, irrespective of
the number of skin lesions
● Paucibacillary or PB Leprosy - refer to a case of leprosy with one (1) to five (5) skin
lesions, without demonstrated presence of bacilli in a slit-skin smear
● Post-Exposure Prophylaxis (PEP) - refers to the intervention or actions to prevent
infection and other harmful effects of the disease after someone has been exposed to the
disease
● Recording - refers to the process of capturing the data of patient/client management over
time. It reflects/gives the health-related services provided to an individual patient
 LEPROSY
● Chronic communicable disease that
affects the peripheral nerves and skin
● Permanent disabilities of the eyes,
hands and feet
● Single or multiple white or red skin
patches
● Lead to definite loss of sensation
● Bacteria called Mycobacterium
leprae
● Transmitted from man to man
 Epidemiology
● Race
○ Leprosy was once endemic worldwide, and no racial predilection is known.
● Sex
○ more common in males than in females, with a male-to-female ratio of 2:1.
● Age
○ Leprosy can occur at any age, but in developing countries, the age-specific incidence of leprosy peaks in
children younger than 10 years, who account for 20% of leprosy cases.
● HIV coinfection
○ HIV coinfection does not seem to affect the ratio of lepromatous to tuberculoid leprosy.
https://www.statista.com/statistics/87
4/leprosy-new-cases-number-worldw
by-region/
https://www.statista.com/statistics/87
4/leprosy-new-cases-number-worldwi
by-region/
● Eliminated in the Philippines as a public health
problem since 1998
● Average of 1,500 — 2,000 new leprosy cases from
2008- 2018
● World Health Organization (WHO) guidelines on the
recommended treatment for patients and on
chemoprophylaxis contact of index cases
● National Leprosy Control Program to attain its
targets as follows:
○ (1) Zero Transmission
○ (2) Zero Disability due to leprosy
○ (3) Zero stigma and discrimination as support
to the global target of Sustainable Development
Goal (SDG) 3.3 particularly the roadmap of the
Global Leprosy Program 2030
● Updates on the policy include the following:
○ guidance on improved management of leprosy cases
○ preventing disabilities newly diagnosed cases
○ practical steps on attaining program targets in developed set-up
● Universal Health Care Law through the FOURmula One Plus (F1+)
for Health Framework
○ framework focuses on service delivery by ensuring accessibility
of essential quality health services at all levels, thereby
preventing the spread of leprosy through the treatment of
existing cases and chemoprophylaxis for contact of index cases
 Objective
Administrative Order 2021, 0004

To update the guidelines on treatment and prevention of leprosy in line with the goal to achieve the
global target of zero leprosy transmission, zero disability and zero stigma by 2030.
 ISLAND OF NO RETURN
● Culion Leper Colony was first founded in 1902
● Dr. Victor G. Heiser was appointed as the Director of Health of the Philippines under Secretary of the
Interior, Dean C. Worcester in 1905
● No known cure
● Estimated it affected more than six thousand people
● Segregation policy to protect the healthy by isolating the “sick”
● Passed on September 12, 1907, Act 1711 of the Philippine Commission
● The law stated that, “the Director of Health and his authorized agents are hereby empowered to cause to
be apprehended, and detained, isolated, segregated, or confined, all leprous persons in the Philippine
Islands.”
A photograph of nurses and patients in the Culion Hospital
● Started with 370 patients in 1906 and grew to over 5,000 in just five years
● “prisoners of hope”
● The “Island of Hope” Heiser promised was better known amongst
Filipinos as “La Isla de Dolor”, or “the Island of Pain”
● Sixty percent of the four thousand and more admitted to Culion died within
the first four years.
Whatever the route of M. leprae’s entry into the human body, the pathogenic
process usually starts in the peripheral nerves. Once bacilli are engulfed by
Schwann cells, the histopathologic changes in nerve and skin – and thus the
type of leprosy that develops – depend on the immunologic resistance of the
person infected, in particular on the cell-mediated immune (CMI) response to
the bacillus and antigens.

Pathogenesis
 Incubation period, risk factors, and Role of Contacts

The incubation period of leprosy is estimated to range from 2 to >10 years.

● PAUCIBACILLARY – 2-5 years
● MULTIBACILLARY – 5 to >10 years

Poverty-associated factors such as low level of education, poor hygiene and food shortages
have been identified as risk factors for leprosy, but the most important risk factors are
associated with intimacy and duration of contact with a leprosy patient, in particular with an
index case with multibacillary leprosy, and the intensity of contact with and physical distance
from the index patient.
 Diagnosis of Leprosy
Diagnosis of leprosy is mainly based on
clinical signs and symptoms.

Only in rare instances is there a need to

use laboratory and other investigations to
confirm a diagnosis of leprosy.
 An individual should be regarded as having leprosy if he
exhibits the following cardinal signs:

Hypo-pigmented or reddish
●
skin lesion(s) with definite 01
sensory loss;
● Peripheral nerve damage, as
demonstrated by loss of
sensation and muscle
02
weakness in the hands, feet
and/ or face;
● Positive skin smear. 03

The diagnosis can be established when two of these three signs are present
 Other signs of leprosy :
● Skin lesion(s) with a decrease or loss of 01
sweating and/or hair growth;
● Constant redness in the eyes from irritation 02
and dryness;
● Loss of eyebrows and eyelashes
(madarosis);
03
● Nasal congestion/obstruction and frequent
nosebleed ;
04
● Collapse of nose bridge
05
 Other signs of leprosy :
● Enlargement of the breast in males (gynecomastia); 01
● Mobile or stiff clawing of fingers and toes;
● Chronic ulcers, usually in the sole of the foot, palm of 02
the hands and fingers.
03
 Patient’s History
The leprosy case history should have the following information:

1. The nature of the first lesion or Ask:

symptom and its progress.
- This is because the skin lesion usually develops
slowly over several months and is not troublesome.
● When did the patient first notice the
lesion?
● What was its appearance?
● How did it feel? Was it painful? Itchy?

Ask:
2. Past treatment ● What did the patient do when he first
noticed the lesion?
● Did he apply any drug(s)?
● What was the effect of this/these drug(s)?
 Patient’s History
The leprosy case history should have the following information:

3. Other illnesses Ask:

- Pay attention to contraindications ● Does the patient have a history of liver disease?
to MDT drugs; or any other ● Allergy o drugs?
illnesses requiring special attention ● If yes, what drugs?
and/or referral.

4. Contact with persons with leprosy Ask:

(PWLs) ● Does/did anyone in the family have leprosy?
- This information will help ● Does he have a friend or acquaintance who
determine the patient’s has/had leprosy?
susceptibility to the disease.
 Leprosy can be classified on the basis of
clinical manifestations and skin smear results.

The Ridley-Jopling classification has seven

(7) types of leprosy:
1. Indeterminate (I)
2. Tuberculoid (TT)
3. Borderline Tuberculoid (BT)

Classification
4. Borderline (BB)
5. Borderline Lepromatous (BL)
6. Sub-polar Lepromatous (LLs)
7. Polar Lepromatous (LLp)
1. Indeterminate (I)
One or a few of hypopigmented or faintly erythematous, ill-defined to well-defined macular
lesions measuring 1-5 cm in diameter.

● Solitary, ill-defined hypopigmented macule on left cheek; only partially anesthetic.

● Solitary, ill-defined, faintly hypopigmented macule on the dorsum of the wrist; minimal surface changes; partially
insensitive.
● Single, slightly hypochromic macule with ill-defined borders on the dorsum of the lower right forearm; minimal surface
changes; partially anesthetic
2. Tuberculoid (TT)
A well-defined, hypopigmented macule or as a raised, erythematous / brown /
copper-colored plaque with a well-defined edge
3. Borderline Tuberculoid (BT)
Either macular or plaque-type lesions numbering 3 to 9 or more and asymmetrically
located on any part of the body. Margin of lesions range from poorly defined to well
defined. Sometimes both forms of margin are seen in one lesion.
4. Mid-Borderline (BB)
This form is unstable. Multiple plaque lesions and, not infrequently, macular
lesions. Lesions are of various sizes and shapes, bilateral, and usually occur in a
more or less symmetric distribution.
● In annular lesions, the inner edge is well demarcated and “punched out”, and
outer edge is ill defined and merges w/ normal-looking skin.
● Minimal loss of sensation and nerve damage is variable.
● BB is not commonly observed and rapidly changes rarely to BT but more often
to BL.
5. Borderline Lepromatous
(BL)
Numerous bilateral, round or oval, macular, diffusely infiltrated, erythematous or hypopigmented
lesions with moderately defined borders. Lesions are usually 2-3 cm in diameter, may have a coppery
hue, and tend to become symmetrical.
● Some loss of sensation on older lesions, no loss of sensation observed on fresh lesions.
● With disease progression, papules, nodules, and plaques, develop over the macular lesions
6. Sub-polar Lepromatous (LLs)
Symmetrically distributed infiltration with prominent macular lesions. Note borderline-type, punched-out patches
on the wrist. Symmetrical infiltration and erythematous macules, with an unusual borderline-type plaque on the
left buttock.Extensive, symmetrically distributed infiltration with almost coalescent macules and plaques. These
lesions are not anesthetic. Note small rounded borderline-type plaque on the left lumbar area.
7. Polar Lepromatous (LLp)
Early lepromatous leprosy with recognizable diffuse infiltration all over face and ears. Fairly advanced
lepromatous leprosy, with symmetrically distributed diffuse infiltration, nodules on face and ears, and madarosis.
Advanced lepromatous leprosy, with marked diffuse infiltration, madarosis and loss of eyelashes. Advanced
lepromatous leprosy with diffuse infiltration coupled with nodules over eyebrows, cheeks, ala nose and chin, as
well as earlobes. Advanced lepromatous leprosy with diffuse infiltration and nodular lesions.
 The World Health Organization (WHO)
classifies leprosy into only three (3) types:
• Single Lesion Paucibacillary (SLPB)
• Paucibacillary (PB
• Multibacillary (MB)
Classification
Complications
 Type 1 Leprosy Reaction (T1R)

T1R is usually observed in the borderline portion

of the spectrum.

Skin lesions are characterized by acute swelling

and redness. Nerves may be painful and tender
because of neuritis, with consequent nerve
damage and disfigurement. In the severe form of
TIR, nerve abscesses may be formed. This
"silent neuritis" may lead to sensory and motor
Complications impairment in the hands, feet, and face.
Arthralgia or arthritis sometimes occurs.
 Type 2 Leprosy Reaction (T2R)

- Also known as ENL (erythema nodosum leprosum)

An example of type III hypersensitivity reaction

(Coombs and Gell classification) or Arthus
phenomenon.

Evanescent, pink-to-red maculopapular, papular,

nodular, or plaque lesions suddenly appear and are
usually accompanied by constitutional symptoms like
Complications malaise and fever, with or without painful swelling in
the joints
 Type 2 Leprosy Reaction (T2R)

The patient may have other associated signs

such as lymph node enlargement, myositis,
arthritis, synovitis, rhinitis, epistaxis, laryngitis,
iridocyclitis, glaucoma, painful dactylitis, acute
epididymo orchitis, nephritis and renal failure,
hepatosplenomegaly, anemia, and-at a later
Complications
stage-amyloidosis.
 Lucio’s Phenomenon
- May be a variant of erythema nodosum
necroticans.

Marked vasculitis and thrombosis of the superficial

and deep vessels result in hemorrhage and infarction
of the skin. Clinically, the skin reaction begins as
slightly indurated, bluish-red, ill- defined, painful, and
rarely palpable plaques with an erythematous halo,
usually developing on one limb but sometimes on
other areas of the body. The lesions are irregular or
Complications triangular.
 Nerve Function Impairment, Neuritis and
Disfigurement
Neuritis (nerve inflammation) in leprosy is usually a
subacute, demyelinating, and unremitting event
involving cutaneous nerves and larger peripheral
nerves.

● More common and severe during leprosy reactions,

mainly in T1R

Sensory and motor neuropathy can lead to secondary

impairments in the upper and lower extremities, such
Complications as muscle atrophy, mobile- and fixed-joint
contractures, bone absorption of digits, and cracks
and wounds.
Classification of
Leprosy
 Lucio’s Phenomenon
- May be a variant of erythema nodosum
necroticans.

Marked vasculitis and thrombosis of the superficial

and deep vessels result in hemorrhage and infarction
of the skin. Clinically, the skin reaction begins as
slightly indurated, bluish-red, ill- defined, painful, and
rarely palpable plaques with an erythematous halo,
usually developing on one limb but sometimes on
other areas of the body. The lesions are irregular or
Complications triangular.
The development of complications can be
effectively prevented through early
detection, correct diagnosis and effective
treatment.
Treatment of
Leprosy
Multidrug Therapy

Only one multidrug regimen is

recommended by the WHO for the
treatment of leprosy. This regimen
consists of a combination of two or three
of the following drugs: rifampin, dapsone,
and clofazimine
Vaccination
Prevention and Control
Vaccination at birth with bacille Calmette-Guérin (BCG) has proved variably effective in preventing leprosy:
the results have ranged from total inefficacy to 80% efficacy.

Chemoprophylaxis
Chemoprophylaxis with dapsone may reduce the number of tuberculoid leprosy cases but not the number of
lepromatous cases and therefore is not recommended, even for household contacts. In addition, single-dose
rifampin prophylaxis is of doubtful efficacy.

Isolation Because leprosy transmission appears to require close prolonged household contact, hospitalized
patients need not be isolated.

“Zero Policy”
The WHO has formulated its new Global Leprosy Strategy 2021-2030. As in the organization's previous
strategy, a holistic approach to leprosy control is advocated, focusing on zero infection and disease, zero
disability, and zero stigma and discrimination.
 DOH Roles and Responsibilities
Disease Prevention and Control Bureau (DPCB) shall:

a. Manage, coordinate and monitor the NCLP including the assessment, introductory
phase and nationwide implementation;
b. Facilitate the yearly donation of Multi-Drug Therapy (MDT) from the World Health
Organization
c. Facilitate the convening of meetings and orientations on treatment and prevention
implementation in coordination with key partner organizations;
d. Facilitate annual assessment of treatment and prevention implementation as part of the
regular NLCP Program implementation Review.
 DOH Roles and Responsibilities
Provincial Health Offices, City Health Offices and Municipal Health Offices shall
encourage to:
1. Formulate and issue policy supporting the implementation
2. Coordinate with the Leprosy Control Program Coordinator at the CHD for identification and
mobilization of available resources for LGUs
3.Provide technical support such as training and advocacy materials to adopt procedures and
control measure in the treatment and prevention of leprosy.
4.Monitor and evaluate implementation at the local level and submit reports to the DOH CHDS
through the Provincial and Regional Leprosy Program Coordinator
Thank you!