LEPROSY (HANSEN’S DISEASE)

Dr. Saida Sharmin

MBBS, MPH (Epidemiology)
 Leprosy
Leprosy (Hansen’s disease) is a chronic
infectious disease caused by Mycobacterium
leprae. It affects mainly the peripheral
nerves. It also affects the skin, muscles, eyes,
bones, testes and internal organ.
Leprosy
Leprosy
Leprosy
 Clinical features
a. Hypo pigmented patches.

b. Partial or total loss of cutaneous sensation

in the affected areas (the earliest sensation
to be affected is usually light touch).

c. Presence of thickened nerves &

d. Presence of acid –fast bacilli in the skin or

nasal smears.
 Epidemiological determinants
Agent:
Leprosy is caused by Mycobacterium leprae.
They are acid fast bacilli.
Source of infection:
It is generally agreed that the multibacillary
cases (lepromatous and borderline
lepromatous cases) are the most important
source of infection.
Epidemiological determinants
Portal of exit:
The nose is the major portal of exit. The
bacilli can also exit through ulcerated or
broken skin of bacteriologically positive
cases of leprosy.
Infectivity:

Leprosy is a highly infective disease

 Cont...
but of low pathogenicity. An infectious patient
can be rendered non infectious by treatment
with dapsone for about 90 days or with
rifampicin for 3 weeks.
Attack rates:
Among household contacts of lepromatous
cases, a varying proportion 4.4% -12% is
expected to show signs of leprosy within
5 years.
Host factors
Age:
Leprosy is not particularly a disease of
children. An individual can get infected any
time depending upon the opportunities for
exposure. Incidence rates generally rise to a
peak between 10 to 20 years of age and then
fall.
Cont...
Sex:
Both incidence and prevalence of leprosy
appear to be higher in males than in females
in most regions of the world.
Immunity:
It is a well established fact that only a few
persons exposed to infection develop the
disease. A certain degree of immunity
Cont...
is also probable through infections with
other related mycobacteria. Cell-mediated
immunity (CMI) is responsible for resistance
to infection with M.leprae.
 Environmental factors
✓ The risk of transmission is predominantly
controlled by environmental factors. i.e., the
presence of infectious cases in the
environment. Humidity favours the survival
of M.leprae in the environment.

✓ Overcrowding and lack of ventilation

within the household favours transmission.

 Mode of transmission
Transmission occurs by:

a. Droplet infection.

b. Contact transmission: Person to person by

close contact between an infectious patient
and a healthy but susceptible person.

c. Other routes.
 Incubation period
Long incubation period, an average of 3 to 5
years. The tuberculoid leprosy have a shorter
incubation period.
Classification:
1. Madrid classification

2. Ridley-Jopling classification

3. The Indian classification.

 Classification

Indian classification Mardid classification

Indeterminate type Indeterminate
Tuberculoid type Tuberculoid; flat; raised
Borderline type Borderline
Lepromatous type Lepromatous
Pure neuritic type (no
skin lesion)
 Classification
Ridley-Jopling classification

1. Tuberculoid

2. Borderline tuberculoid

3. Borderline

4. Borderline lepromatus

5. Lepromatus
Clinical classification(WHO)
Multibacillary (MB) type:

In this type bacillary load is high. It includes

all lepromatous & borderline forms where
Skin smear is positive & /or the numbers of
skin lesions are 6 or more or one nerve
involvement(approximately 40%).
Clinical classification(WHO)
Paucibacillary (PB) type:
Here the bacillary load is low, hence bacilli
cannot be demonstrated in routine skin
smear. It includes tuberculoid &
indeterminate forms where skin-smear is
negative & number of skin lesions 1-5/or
only one nerve involvement.(approximately
60%).
Deference between Paucibacillary & Multibacillaryleprosy

Traits Paucibacillary leprosy Multibacillary leprosy

1. Leprosy Extremely few in the Present in enormous in

bacilli patches of the affected areas .
paucibacillary leprosy.

2. Skin smear Skin smears taken from Skin smears are always
affected area are usually positive for bacilli.
negative for bacilli.

3. Skin lesions Usually 1-5 Many (>6)

number
4. Distribution Asymmetrical Symmetrical

5. Surface Rough, dry, hairless Smooth and shiny

Deference between Paucibacillary & Multibacillary
leprosy
Traits Paucibacillary leprosy Multibacillary leprosy

6. Sensory loss Marked Slight or more

7. Diagnostic Presence of sensory Presence of bacilli in

criteria loss in affected area . skin smears .

8. Infectiousness Nil or negligible Highly infections

9. Outlook Good Poor if untreated

 Indian classification
Indeterminate type
This denotes those early cases with one or two
vague hypopigmented macules and definite
sensory impairment. The lesions are
bacteriologically negative.
Tuberculoid type
This type denotes those cases with one or two
well defined lesions, which may be
 Cont...
flat or raised, hypopigmented or
erythematous and are anaesthetic. The
lesions are bacterologically negative.

Borderline type

This type denotes those case with four or more

lesions which may be flat or raised, well or ill
defined, hypopigmented or erythematous and
 Cont....
show sensory impairment or loss. The
bacteriological positivity of these lesions is
variable. Without treatment, it usually
progresses to lepromatous type.

Lepromatous type
This type denotes those cases with diffuse
infiltration or numerous flat or raised,
Cont...
poorly defined shiny, smooth, symmetrically
distributed lesions. The lesions are
bacterologically positive.
Pure neuritic type
This type denotes those cases of leprosy
which show nerve involvement but do not
have any lesion in skin. These cases are
bacteriologically negative.
 Case definition
✓ A person is said to be leprosy case who has
the active clinical signs of leprosy with or
without bacteriological positivity & who has
not yet completed a full course of treatment.

✓ Any one of the 3 Cardinal signs is sufficient

to a leprosy case:
 Cont....
• Skin patches with loss of sensation
• Thickened / swollen peripheral nerve with or
without pain.
• AFB positive skin smear.
Skin smear examination
It is useful for diagnosis & classification of
leprosy in doubtful cases. Skin smear will be
done in all cases classified as MB & in PB cases
only if required, i.e. in doubtful cases.
 Skin smear examination
Material from the skin is obtained from an
active lesion and also from one of the ear lobe
by the “slit and scrape method”.
Conventionally two sites are examined.

Diagnosis
▪ Clinical diagnosis is made by physical
examination of entire skin of the patient
 Diagnosis
▪ For any change, Searching for palpable
enlarged peripheral nerves & examining the
nose, eyes and mouth.

▪ There are 3 cardinal signs of leprosy;

usually more than one of these signs are
present, but presence of only one of them
may be sufficient to diagnosis.
 Cont….
These are:

1. Diminished sensation to cotton wool touch

in a patch in the skin
2. Thickening of peripheral nerves in specific
sites

3. Demonstration of acid fast mycobacteria in

a skin smear.
Feather test
 Laboratory diagnosis
1. Microscopic examination of smears from
skin lesions or nasal mucous membrane.

2. Mouse foot-pad culture

3. Histamine test

4. Histological examination of biopsy material

5. Immunological test( lepromin test, ELISA)

 Treatment
Multibacillary leprosy:

The WHO has recommended the following

combination of the drugs of adult
multbacillary cases of leprosy

✓ Rifampicin : 600mg, once monthly, given

under supervision.

✓ Dapsone : 100mg daily, self administration.

 Cont ...
Multibacillary leprosy
✓ Clofazimine : 300mg once monthly under
supervised, and 50mg daily, self
administrated.
Where clofazimine is totally unacceptable
owing to the colouration of skin, its replaced
by 250mg to 375mg self administrated daily
doses of ethionamide or protionamide.
 Cont ...
For paucibacillary leprosy:

The recommended standard regimen for adult

is -
✓ Rifampicin: 600 mg once a month, for 6
month under supervised.

✓ Dapsone: 100 mg (1-2 mg/kg body weight)

daily, for 6 month (self administered).
Drugs (Leprosy)
Drugs (Leprosy)
 Multibacillary leprosy
Standard treatment for children aged 10-14
years is as follows:

➢ Rifampicin: 450 mg, once a month, given

under supervision.

➢ Dapsone : 50 mg, self administered.

➢ Clofazimine : 150 mg once a month

supervised; and 50 mg every other day.
 Paucibacillary leprosy
Standard treatment for children aged 10-
14 years is as follows:
➢ Rifampicin : 450 mg once a month
supervised.
➢ Dapsone : 50 mg, daily, self administered.
Children under the age of 10 years should
receive appropriately reduced doses of the
above drugs.
 Duration of treatment
The treatment duration varies according to
the type of disease .The recommendations are
as follows:
✓ Multibacillary: MB blister packs for 12
months, within 18 months.
✓ Paucibacillary: PB blister packs for 6
months, within 9 months.
Leprosy is a social disease
Leprosy is a social disease in our country,
because -

✓ Leprosy is often considered by common

people in the society as a curse.
✓ They considered it as a hereditary disease.

✓ They try to keep the families of leprosy cases

isolated from society.
 Cont....
✓ No one wants to make relationship or
kingship with them.

✓ Leprosy cases with bodily deformities are

really burden in the society.
 Questions
❖ Classify leprosy?

❖What are the cardinal features of

Leprosy?

❖Mention the control of Leprosy?