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Making Sense of ... Leprosy
(Hansen's Disease)

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Leprosy

What is leprosy?

Leprosy, also known as Hansen's Disease, is a chronic infectious disease caused by the bacterium Mycobacterium leprae.

Leprosy usually affects the skin and peripheral nerves, but can manifest in a variety of ways.

Multibacillary (lepromatous) Hansen's disease is associated with symmetric skin lesions, nodules, plaques, thickened dermis, and frequent involvement of the nasal mucosa, resulting in nasal congestion and nose bleeds.

Patients living with paucibacillary (tuberculoid) Hansen's disease have a milder form, characterized by one or more hypopigmented skin macules.

Where is leprosy usually found?

In 2002 five nations were thought to have a major problem with leprosy; Brazil, Madagascar, Mozambique, Tanzania, and Nepal. However, in 1995, the disease was endemic in more than 100 countries, and it still occurs widely in southern and south eastern asia, as well as the eastern mediterranean area, despite a WHO eradication campaign.

The campaign aimed to reduce the prevalence of the disease to below 1 in 10,000 in affected countries by 2000; the target was achieved in many, but there is now fear of under reporting in some countries, as the stigma remains - and the project teams have moved on.

How common is leprosy?

Theoretically, the disease has reached the 1 in 10,000 target in every nation - but this hides the fact that some areas have achieved much lower prevalence, while others have failed; indeed, in parts of India, the disease is thought to be increasing.

How is leprosy transmitted?

The main route - possibly the only one - is droplet / aerosol infection from the nose of an infected person.

Can leprosy be spread from person-to-person?

As the disease is very slow in its progress, prolonged close contact may be required.

For centuries, it was thought the disease was spread by touch, via the skin. This is now known to be false. Neither is the disease spread by sexual activity or childbirth.

Who is most at risk from leprosy?

People living in overcrowded, poorly ventilated homes in warm or hot climates. Genetic research has shown that some people carry five times the normal risk of catching the disease, if exposed to it.

What are the symptoms of leprosy?

Lepromatous leprosy is characterized by a chronically stuffy nose and many skin lesions and nodules on the front and back of the body.

Sensation loss starts at the extremeties - the fingers and toes - and may initially affect a small area of skin.

Most of the problems of leprosy are caused by sensation loss, which inevitably leads to injuries being unnoticied - or their seriousness unrealized - and so they become infected. In advanced cases, gangrene will follow.

Tuberculoid leprosy features well-defined skin lesions with total sensation loss which can lead to unnoticed injuries and infection.

Dimorphous leprosy creates skin lesions characteristic of both forms.

What are the long term effects of leprosy?

All forms of the disease eventually cause peripheral neurological damage (nerve damage in the extremities) manifested by sensory loss in the skin and muscle weakness. People with long-term leprosy may lose the use of their hands or feet due to repeated injury resulting from lack of sensation.

What is the mortality rate for leprosy?

The statistics suggets that some 4000 people die each year as a result of living with leprosy; but it is not the disease itself, rather an aincreased risk of problems associated with the disease.

For example, blindness is a widespread feature of advanced disease, and studies suggest that it increases mortality, compared to sighted people with Hansen's, by five times. Young blind patients carried the highest relative risk. Similarly, the nerve damage, specifically affecting sensation, means that burns scalds and other injuries may not be treated appropriately, as the patient gets no pain.

Even after relapse, which occurs in some patients whose treatment is stopped before complete bacterial negativity, death is not directly caused by the disease.

How is leprosy diagnosed?

Diagnosis is established by isolating Mycobacterium leprae from the mucous membranes of the nose or from skin lesions.

The Lepromin skin test can be used to distinguish lepromatous from tuberculoid leprosy, but is not used for diagnosis.

Is there a treatment for leprosy?

Leprosy management is based on three principles: early detection, appropriate treatment, and the prevention of disabilities and rehabilitation.

For many years, Dapsone was the treatment of choice; however, it did require very long-term treatment, it does have vicious side effects, and in recent years, has been undermined by drug resistance.

Since 1995, the World health Organization has recommended and supplied two drug treatment regimens:

For aucibacillary leprosy (one to five skin lesions) Rifampicin and Dapsone for 6 months.

For multibacillary leprosy : (more than five skin lesions) Rifampicin, Clofazimine and Dapsone for 12 months.

Thalidomide has been approved for use against erythema nodosum leprosum, a complication of leprosy which causes fever, skin lesions, and other symptoms.

Is there a way to prevent infection?

Prevention consists of avoiding close physical contact with untreated people. This works; for centuries, it was the only measure against the disease, and it effectively eradicated the dsease from many countries where it had been endemic.

Now that the disease is better understood, isolation is not permanent, and is less cruel - though the stigma of leprosy remains an issue.

People on long-term medication are not infectious. They do not transmit Mycobacterium leprae.

Is there a leprosy vaccine?

Not yet. Various projects have found possible lines of research, but there is no product in sight at this time.

Can leprosy be controlled environmentally?

The World health Organization is supporting an eradication campaign which involves education and earlydiagnosis as well as treatment; as with all diseases, early diagnosis reduces problems for the individual, as well as reducing further spread and saving money. But the centuries-old stigma attached to leprosy has produced modern problems - disease reporting is probably woefully below the real levels in some endemic areas, and people still hide their skin lesions rather than come forward for treatment and possible rejection by their community.

Is there legal protection for workers and others?

Many countries have had laws to protect people from leprosy; usually by restricting the movement s of those living with the disease. In our more enlightened times, most of these laws are obsolete, redundant and unenforceable. As with most dieases, the laws of neglgigence where you live are the laws that matter.

What can be learned from history?

First that it would be unwise to assume the battle against leprosy is won. Statistics claim that 15,000,000 with leprosy and its disabilities 20 years ago have been reduced to 500,000 now; many of them cured, simply living with the disabilities that they've got from the disease. the truth is almost certainly not so pleasant. Diagnosis is still late in many cases, the stigma lives on, and treatment without adequate supervision and support can be ineffective.

The battle is NOT won. Not by a long way.

Bibliography and Further Information Sources

If this article hasn't answered your question, email me at the address below, and I'll try to get the information you seek. I regret I cannot assist with individual cases or essays and school projects, but if it's something I've missed, I'll be happy to try and help.

Article written by Andrew Heenan BA (Hons), RGN, RMN

First Published: 17 April 2007
Last updated: 18 March 2012
© Andrew Heenan 2007 et seq
 

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