History of Leprosy

Abstract

Hansen’s disease, more commonly known as Leprosy is a disease caused by the bacteria Mycobacterium Leprae. When it was first discovered individuals affected were once feared due to it being a highly contagious and devastating disease, or so they thought. Today we know that it is a very curable and hard to spread disease, though if left untreated it can have very significant impacts for life on one’s health. Though curable, if left untreated the individual can become paralyzed and suffer from nerve damage for the rest of their life. Once an infected individual starts treatment, they are no longer able to spread the disease to a healthy individual.

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More commonly found in countries such as Asia, Africa and other tropical climate countries, it does have a significant impact on those living in the United States. Due to the long incubation period, between 5-20 years, the infected individual could leave a country where the disease is prevalent and bring it to a country where the prevalence is far less and could infect individuals without realizing they have the disease themselves.

Introduction to the Disease Leprosy

Hansen’s Disease, or as it is more commonly known, Leprosy is a significant health issue throughout the world. It is an infection that is caused by the bacteria Mycobacterium Leprae, which is a significant granulomatous infection of the skin and the peripheral nerves which are all of the nerves in the human body that lie outside of an individual’s spinal cord and brain. It was a disease that was known about thousands of years ago in India and China, however just over a hundred years ago a man named Armauer Hansen discovered that bacteria that causes Leprosy.

Most commonly found in hot tempered climates such as Europe, Asia and African countries, this disease is also found in the United States.

Nature of the Disease

Leprosy is known as a chronic disease. A chronic disease is a condition or disease that is considered to be a long lasting illness, or an illness that takes a while for signs/symptoms to appear. The average incubation period for Leprosy is 5 years, however it may take up to 20 years for an infected individual to know that they are infected by the bacteria, and therefore calls under a chronic disease. This long incubation period can cause an infected individual who does not know that they are infected to bring the disease into an area where the disease is not prevalent, and can cause it to spread.  The underlying cause of Leprosy is the bacteria Mycobacterium Leprae.

Clinical Picture

The specific way of transmission for Leprosy is still being discovered and explored.  It is believed that prolonged contact between an infected individual and an unaffected individual is enough to cause the disease to spread, however it is still being studied. Another possible thought is that it can be transmitted through an insect from an infected person to unaffected persons. Another transmission possibility that is being explored is that the disease may be passed on when an infected individual coughs or sneezes and a healthy individual breaths in the droplets that may potentially contain the bacteria. It has been determined however that this is not a disease that gets spread through things such as shaking hands, hugging, or sitting near an infected person. Another determination that has been made is that this disease will not spread from an infected pregnant mother into their unborn baby during pregnancy, nor will it be spread through sexual contact.

Signs and symptoms of Leprosy may vary, as well as the noticeability of these symptoms.  Those living in areas of possible infection should be regarded as having the disease if they show any of the fundamental signs for being infected. The number one sign for an individual that has leprosy are skin lesions. These skin lesions may come singularly, or the individual may have multiple.  These skin lesions may have sensory loss meaning they may not be able to feel something as sharp as a pin prick, or as soft as a simple touch. An infected individuals skin lesions may be pigmented less that the surrounding       un-affected skin, or they may be red and/or copper colored. Commonly skin lesions are flat, raised or show up as nodules.  Other symptoms of Leprosy can include nerves that have been thickened, painless ulcers on the soles of ones feet, painless swelling or lumps on the face or earlobes, and growths on the skin. When the disease infects an individual’s mucus membranes symptoms can include stuffy nose and nosebleeds. As the disease progresses the more severe the damage becomes. If the individual does not seek treatment for Leprosy, they may suffer severe nerve damage that can result in sensory and motor impairment as well as deformities and disabilities.

An individual who believes they are infected should immediately see a doctor. The longer and individual waits to be test for Leprosy the more irreversible damage that may be done to their bodies. A test known as a skin smear test can be performed to determine if an individual has Leprosy and what type of Leprosy that individual has. This test is considered valuable, cost-effective test to conduct on potentially affected patients. The smear allows the doctor to estimate the number of “acid-fast” bacteria that is present on that patient. This estimate is then reported as that person’s bacterial index and helps to determine which type and the severity of Leprosy they possess. It also allows them to determine which treatment suites the patient best.  When completing the test the smears are taken from 6 different sites, the earlobes, elbows and knees. The site of the skin lesions will also be tested. The test is repeated as determined by the doctor, but are typically repeated annually. This allows the doctor to also monitor the individuals reaction to the treatment once started.

To complete this test the doctor will clean the skin with a 70% alcohol solution and let the skin air dry. The skin is then pinched or possibly clamped if required. Local anesthesia is administered if necessary but not typically required. An incision typically 3-5 millimeters long and 2-3 millimeters deep is made with a razor blade. The inner surface of the wound is scraped with the blade to collect tissue fluid as well as dermal tissue. Once the smear is obtained it is sent to the National Hansen’s Disease program to allow a specialist to read and collect results.

Clinical studies use what is known as Ridley-Jopling system which includes five classifications of leprosy, and each classification is based on the severity of an infected individuals symptoms. The 5 different types of Leprosy include tuberculoid leprosy, Borderline tuberculoid leprosy, Mid-borderline leprosy, Borderline lepromatous leprosy and Lepromatous leprosy. Tuberculoid leprosy comes with a small number of flat lesions, some may be large, and there may also be numbness or nerve involvement. This type of Leprosy may heal on its own, may persist or may progress. Borderline tuberculoid leprosy has similar lesions, however there are typically a larger number and have more nerve involvement. This type may persist, revert back to tuberculoid or advance into another form of the disease. Mid-borderline leprosy may include reddish lesions and may include moderate numbness, swollen lymph nodes and more nerve involvement. This type of leprosy may regress, persist or could form into another type.  Borderline lepromatous leprosy often comes with multiple lesions, flat and raised bumps and an increase in numbness of the skin.  This type too may persist, regress or progress into another type. Finally lepromatous leprosy includes a large number of lesions with the bacteria included, hair loss, severe nerve damage, nerve thickening, limb weakness and can include disfigurement.  This type of leprosy does not regress.

The likelihood of someone dying from this disease is minimal unless left untreated. Typically if left untreated the individual will suffer irreversible damage but may not die. Currently the main treatment for leprosy includes a multiple drug treatment or commonly referred to as MDT. An MDT consists of using multiple antibiotics, often 2-3 to prevent the body from becoming immune to any of them due to overuse. The antibiotics are required to be taken for a span of time, currently it is best to take for 1 to 2 years, and if stopped the disease could come back so it is very important that the infected individual sticks to taking their antibiotics as required and recommended by their doctor.  The typical drugs that are given with this MDT are dapsone, rifampicin, and clofazimine which is added for some types of Leprosy.

If Leprosy is left untreated the nerve damage experienced from this disease can result in paralysis, crippling of the hands and feet and in more advanced cases the individual may experience multiple injuries due to the lack of sensation in their skin.  Corneal ulcers and blindness are also possible late term issues if the disease is left untreated and if the facial nerves of the affected.  Advanced Leprosy may also cause loss of eyebrows or what is known as a saddle-nose deformity due to damage to their nasal septum. Other possibilities if the disease is left untreated can include paralysis and crippling of one’s hands and/or feet, shortening of the individuals toes or fingers due to what is known as reabsorption, non-healing sores or ulcers on the bottoms of the feet, redness and pain around the area of infection, as well as burning sensation in the skin.

The MDT that is used can kill the bacteria that causes it, and it will prevent it from getting worse if the drug regimen is kept up with, but the nerve damage cannot be reversed. The earlier that the individual is diagnosed with this disease, the easier it will be to cure it. Once an individual is treated the disease is no longer able to be spread.

Descriptive Epidemiology

Statistics

Leprosy is considered a rare disease within the United States, however around the world there are at least 2 million people that are permanently disabled due to this disease. More than 95% of people have a natural immunity to it and therefore it is hard to contract. In the United States there are typically between 150-200 new cases annually. Worldwide there are typically 700,000 new cases each year.

Populations at Risk

Like the risk for many things, your chances of contracting Leprosy increase if you live in a country where the disease is prevalent. According to the WHO organization, between 2011 and 2015 countries that were at most risk for contracting Leprosy included places like Africa (Democratic Republic of Congo, Ethiopia, Madagascar, Nigeria, Tanzania, Mozambique); Asia (Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka); and the Americas (brazil). During this study, it was discovered that there were a total of 136 countries that reported cases of Leprosy. India reported 127K of these cases which made up a total of 60% of all the new cases around the Globe. Brazil following behind with 26K or 13% of the new cases, and Indonesia at 17K or 8%. After these 3 areas no other areas had reported more than 10K cases.

Trends

Leprosy still affects over 7 million people world wide today, whether it’s people who have the disease and are currently being treated, or people who have it but cannot get the treatment though it is free. This number also includes expected infections as most people do not realize they are infected for a long period of time. Due to organizations such as WHO that are helping to educate people on the disease there is an increase in knowledge, but many are still unaware of what to do and how to treat it, or are in a country that treatment is hard or impossible to receive.

Outlook

The outlook of Leprosy is still unknown. The MDT drugs have significantly helped those infected and they are continuing research on how to improve the drug still. Less people are affected than in the past and as long as people get the treatment required they are able to live normal lives, however the fact is that many people still cannot access the drugs even though there is no cost to them, and it is still being worked on to get these countries that cannot afford the treatment the ability to help their infected populations.

Public Health

Interventions

In 2016 the WHO launched a global strategy that’s main goal was to create a leprosy-free world. To do this the organization came up with three main pillars.  The first of the three pillars is to strengthen government ownership, coordination and partnership. To do this they want to ensure that there are adequate resources given to the leprosy programs, contribute health coverage that focuses on children, and “underserved” populations, conduct operational research on all aspects of the leprosy disease and strengthen the surveillance of it. The second pillar is to stop leprosy and its complications. They intend on doing so by strengthening and improving patient and community awareness, promote early detection and work toward improving treatments. The final pillar is to stop discrimination and promote inclusion. To do this goal is to include the community, run community based rehabilitation, work toward abolishing discriminatory laws and promote inclusion.

Disease Control and Prevention Efforts

In the 1990s a Leprosy elimination campaign was launched after the World Health Assembly took place. At the time the elimination of leprosy was described as reducing the frequency of leprosy patients receiving antimicrobial therapy to less than 1 of 10,000 people. Their thoughts during this was that once the amount of infected people reduced that the disease would slowly disappear. The MDT was than developed because the original drug dapsone was becoming resistant against. In 1985 it was estimated that 12 million people or 12 per 10000 people were infected. Later in 2002 there were 597,000 registered cases and 719,000 new cases were found. The MDT has resulted in 11 million people that have had Leprosy were cured.

Conclusions

Although in the past Leprosy infected individuals were isolated and ostracized from society, as it was considered a mysterious disease, and in some countries it was considered a curse.  Today treatments are effective and the disease can be cured, but the individual affected needs to ensure that they follow strict treatment guidelines to prevent it from returning. They also may need to learn how to live differently as once the body suffers from nerve damage it cannot be reversed.

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While effective treatment is available it is still a prevalent disease in underdeveloped countries, mainly those with tropical climates. If a person suspects they are suffering from this disease they need to seek medical treatment and ensure that they do not spread the disease to healthy individuals. The transmission of this disease is still being discovered to this day and may never fully be explained.

References

• (2018, September 13). Preparation and Examination of Skin Smears. Retrieved from    https://www.hrsa.gov/hansens-disease/diagnosis/skin-smears.html
• (2019, March 14). Leprosy. Retrieved from https://www.who.int/news-room/fact-sheets/detail/leprosy
• Legua, P. (2018). Leprosy. International Journal of Infectious Diseases, 73(sS), 66–66. https://doi.org/10.1016/j.ijid.2018.04.3574
• Marcos, L., Conerly, S., Walker, S., & Marcos, L. (2014). Leprosy. The American Journal of Tropical Medicine and Hygiene, 91(2), 216–216. https://doi.org/10.4269/ajtmh.13-0668
• Souza, C., Rocha, A., Da Lima, R., & Souza, C. (2015). Leprosy. Hygeia : Revista Brasileira de Geografia MeIdica e Da SauIde, 11(20). Retrieved from http://search.proquest.com/docview/1727698611/