TOPIC

LEPROSY AS AN ENVIRONMENTAL

DISEASE

PRESENTER

Relindis K Fofung PUBH-8165-10 Environmental Health Service Learning Project

Walden University October, 2010 Professor: Dr. Raymond

Thron

OUTLINE

Introduction History of leprosy A neglected Tropical Disease Other Neglected Tropical

Diseases Etiology and Transmission M. leprae close “cousins” Types of Leprosy and

symptoms Diagnosis Reasons for the late diagnosis

Contributing Factors Enzootic Leprosy-Armadillos

and Cats Indigenous Cases of Non-

human Etiology Morbidities from Leprosy Current Global Statistics Leprosy in the Americas Treatment Elimination Strategies Elimination in Progress References

INTRODUCTION - LEPROSY Called Hansen’s Disease - Chronic and disfiguring Caused by Mycobacterium leprae Has high affinity for cooler body parts Is a neglected Tropical infectious disease Diagnosis in the US is always late Treatment is very effective The National Hansen's Disease treatment center is

in Carville, Louisiana.

HISTORY OF LEPROSY Referred to in Biblical literature Historically documented since 600 BC (WHO-LEPROSY)

Common in Chinese in 1518 (Luesink, 2010) Was of curse or insect bite etiology beliefs Imported to Europe 1860s to 1940s by Chinese

immigrants (Luesink, 2010)

M. leprae discovered in 1873 by Hansen, Gerhard, A.

First pharmaceutical drug was dapsone in 1940’s

A Neglected Tropical Disease

Not common in Developed Countries Neglect ed - Low incidence/mortality Common in more than 70

countries Not much attention is paid to it Most often has efficient

treatment(WHO NTD)

Some Neglected Tropical Diseases

Chagas disease , Schistosomiasis, Filariasis, Buruli ulcer, Dengue Fever, Dracunculiasis (guinea-worm disease) Trypanosomiasis) (WHO NTD)

LEPROSY ETIOLOGY & TRANSMISSION

Caused by M. leprae (WHO NTD) Respiratory droplets transmission From person to person From enzootic animal to human Incubation period of 3 to 40 years

Mycobacterium leprae close "cousins”

M. tuberculosis M. ulcerans M. intracellulare M. avium M. xenopi M. simiae M. kansasii

TYPES OF LEPROSY AND SYMPTOMS

Tuberculoid or paucibacillary - Mild form of Leprosy- One or more light skin-blotchesLepromatous - Multibacillary - Symmetrical rash - Widespread (WHO – Leprosy)

SYMMETRICAL RASH ARM & TORSO

FEW RED LEPROSY BLOTCHES

ARM AND ELBOW INVOLVEMENT

DEFORMED DIGITS

SYMMETRICAL LEPROSY RASH ON LEGS

ARM WITH LEPROSY RASH

LEPROSY INFECTED EYE

KNEE INVOLVEMENT

DRY AND SCALY LEPROSY SKIN

DRY SCALY LEPROSY SKIN

LEPROMATOUS EAR LOBE

LEPROMATOUS EAR LOBE

VASCULITIC ULCERATIONS-LUCIO PHENOMENON

See more atFatal Lucio phenomenon

This resemble buruli ulcer

DIAGNOSIS METHODS

Symptoms and Physical Examination Family and Travel History Possible exposure to risk factors Medications Acid Fast stain of Biopsy PCR and FITE Tests See WHO – Diagnosis of Leprosy.

REASONS FOR LATE DIAGNOSIS

Social stigma due to disfiguration Inability to grow M. leprae in

Laboratories Symptoms Resemble other diseases Many Doctors have little experience

in the disease (Nature Reviews) Most US Physicians are untrained to

diagnose leprosy

References:

1. Nature Reviews. Neurology. Nerve damage in leprosy and its management.

CONTRIBUTING FACTORS IN THE AMERICAS’ LEPROSY

Genetics disposition Environmental conditions. Low literacy level Malnutrition Poverty, per Oxford Journal Exposure to nine banded armadillo (Truman, NIH, 2005)

Globalization and Ease of Travel

1. Kerr-Pontes, L. Barreto, M., Evangelista, C., Rodrigues, L., Heukelbach, J and Feldmeier, H. (2006) Oxford Journals. International Journal of Epidemiology. Socioeconomic, environmental, and behavioural risk factors for leprosy in North-east Brazil: results of a case–control study.

2. Truman, R. (2005). Leprosy Review. Leprosy in wild armadillos. National Hansen's Disease Program, DHHS/HRSA/BPHC, LSU-SVM, Baton Rouge, Louisiana 70803, USA.

INDIGENOUS CASES OF NON-HUMAN ETIOLOGY LEPROSY Texas armadillo hunter develops Leprosy

(Becker, Kowalewski, & Martin IV,2009).

Brazil two fold increase leprosy incidence with armadillo exposure

(Deps, Alves, Gripp, Aragao & Guedes, 2008)

Indigenous US lepers (Dr. Franco-Paredes and ABC News)

References:1. Becker, L., Kowalewski, C., & Martin IV, J. (2009). Nonpruritic erythematous plaques. Journal of Family Practice, vol.

58 pp. 657-659 2. Deps, P., Alves, B., Gripp, C., Aragao, R.,and Guedes, B. (2008). Contact with armadillos increases the risk of

leprosy in Brazil: A case control study. Indian Journal of Dermatology, Venereology & Leprology, vol. 74, pp. 338-342.

3. Dr. Franco-Paredes and ABC News. From Plague to Leprosy: 7 Diseases We'd Forgotten About

ENZOOTIC LEPROSY-ARMADILLO 30 years study in 5000 armadillos

Confirmed armadillo leprosy Common in Arkansas, Louisiana, Mississippi

and Texas M. leprae detected in Colombian Armadillos by

PCR (Cardona-castro, Beltrán, Ortiz-Bernal and Vissa, 2009)

Common in people closely associated with armadillos (Truman, 2005 and Becker, Kowalewski & Martin IV, 2009)

References:

1. Truman, R. (2005). Leprosy Review. Leprosy in wild armadillos. National Hansen's Disease Program, DHHS/HRSA/BPHC, LSU-SVM, Baton Rouge, Louisiana 70803, USA.

2. Cardona-castro, N., Beltrán, J., Ortiz-bernal, A., & Vissa, V. (2009). Detection of Mycobacterium leprae DNA in nine-banded armadillos (Dasypus novemcinctus) from the And. Retrean region of Colombia. Leprosy Review, vol. 80,pp. 424-431

2. Becker, L., Kowalewski, C., & Martin IV, J. (2009). Nonpruritic erythematous plaques. Journal of Family Practice, vol. 58 pp. 657-659

ENZOOTIC LEPROSY-ARMADILLO cont Other M. leprae reservoirs are: Chimpanzees and mangabey monkeys (NIH) Monkey to monkey transmission observed M. lepraemurium causes

cat and mice leprosy Mice develop nerve damage but not cats Cat leprosy leproma look like humans M. lepraemurium is a non-human pathogen

ARMADILLO

ARMADILLO

MORBIDTIES FROM LEPROSY Irreversible peripheral nerve damage

Loss of sensation in affected areas Ulcers and loss of digits Blindness Facial distortion Stigmatization and social seclusion Disabilities link:

FACIAL AND HAND DEFORMITIES

Current Global Statistics 121 Countries reported new cases in 2008

Total global new cases in 2008 was 249, 007 Significant decline from 2002 of 620, 638 South east Asia reported most with 167, 505 Eastern Mediterranean with the least, 3, 938 By country, India lead with new cases, 134,

184 Brazil came in second with 38, 914

(WHO-WER, 2009)

WHO. Weekly Epidemiological Report (WER). 14 august 2009, No. 33

2008 NEW CASE FROM COUNTRIES REPORTING MORE THAN 1000 CASES

WHO:NEW CASES REGIONAL DATA

LEPROSY IN THE AMERICAS

1978 to 1985 Indochinese refugee to USA

US epidemic peaked in 1985 But declined in 1988 (Mastro, Redd & Breiman, 1992)

Today 80% of all cases is occur in Brazil Brazil had 38, 914 new cases in 2008 Venzuela was second with 586 (WHO, WER,

2009)

High incidence due to environmental and social behaviors (Kerr-Pontes, Barreto, Evangelista, Rodrigues, Heukelbach, & Feldmeier, 2006)

TREATMENT

Multi antibiotic drug therapy Anti inflammatory drug treatment Treatment differ with form of the

disease Physical and supportive therapy Reconstructive surgery (eye and

orthopedic)(WHO NTD)

PREVENTION In the US, new cases are reportable to the

CDC National Hansen's Disease Programs in Baton

Rouge, Louisiana clinics care for patients Strict follow up treatment with Multidrug

therapy Free drugs from Hansen’s Disease Program Vaccination with BCG argued as ineffective

and unethical (Mangla. 1993)

References: Mangla, B. (1993). Leprosy vaccine debate in India re-ignited. Lancet, vol. 342, p. 233.

ELIMINATION STRATEGIES

Surveillance and monitoring Raise awareness of signs and symptom Political commitment (WHO NTD)

Identification of Risk factors (WHO-leprosy)

Sustainable Multi drug therapy and health education Encourage and gain public trust to seek help early Ease accessibility to diagnosis (WHO NTD)

Enable easy national surveillance and monitoring Discourage stigmatization through education (WHO NTD)

References:1. WHO Neglected Tropical Diseases (NTD). 2. WHO-Leprosy. Retrieved from

ELIMINATION IN PROGRESS

Worldwide Progressive drop in new case since 2002 4% drop from 2007 to 2008 From 258, 133 in 2007 to 249,007 in 2008 Significant decline from 620, 638 in 2002 (WHO WER) Excellent Case of Sri Lanka (WHO NTD) Use of social marketing starting in 1990 By 1996 completely eliminated in the Nation In all 20,000 cases diagnosed and treated effectively(WHO

NTD)

References:1. WHO. Weekly Epidemiological Report (WER). 14 august 2009, No. 33 . 2. WHO Neglected Tropical Diseases (NTD).

REFERENCES 1

1. Becker, L., Kowalewski, C., & Martin IV, J. (2009). Nonpruritic erythematous plaques. Journal of Family Practice, vol. 58 pp. 657-659

2. Cardona-castro, N., Beltrán, J., Ortiz-bernal, A., & Vissa, V. (2009). Detection of Mycobacterium leprae DNA in nine-banded armadillos (Dasypus novemcinctus) from the And. Retrean region of Colombia. Leprosy Review, vol. 80,pp. 424-431.

 3. Deps, P., Alves, B., Gripp, C., Aragao, R.,and Guedes, B. (2008).

Contact with armadillos increases the risk of leprosy in Brazil: A case control study. Indian Journal of Dermatology, Venereology & Leprology, vol. 74, pp. 338-342.

4. Dr. Franco-Paredes and ABC News. From Plague to Leprosy: 7 Diseases We'd Forgotten About

5. Kerr-Pontes, L. Barreto, M., Evangelista, C., Rodrigues, L., Heukelbach, J and Feldmeier, H. (2006) Oxford Journals. International Journal of Epidemiology. Socioeconomic, environmental, and behavioural risk factors for leprosy in North-east Brazil: results of a case–control study.

6. Kumari R, Thappa D. and Basu D. A fatal case of Lucio phenomenon from India Dermatology Online Journal. Vol. 14. Retrieved from

REFERENCES 2

7. Luesink, D. (2010). Leprosy in China: A History. Pacific Affairs, vol. 83, pp. 5-6. 8. Mangla, B. (1993). Leprosy vaccine debate in India re-ignited. Lancet, vol. 342, p. 233. 9. Truman, R. (2005). Leprosy Review. Leprosy in wild armadillos. National Hansen's

Disease Program, DHHS/HRSA/BPHC, LSU-SVM, Baton Rouge, Louisiana 70803, USA. Retreived from http://www.ncbi.nlm.nih.gov/pubmed/16248207

10. WHO – Diagnosis of Leprosy. 11. WHO - Leprosy. 12. WHO. Neglected Tropical Diseases (NTD). Retrieved from

http://whqlibdoc.who.int/publications/2009/9789241598705_eng.pdf

13.. WHO. Weekly Epidemiological Report (WER). 14 august 2009, No. 33