How health education, vaccinations curb leprosy – Doctors
As the world marks the Leprosy Day on Tuesday, governments and health workers have been advised to focus more on public health education to curb ignorance of the disease, as well as clinical management of active cases and contacts. The teaching should also focus on the need for confirmed leprosy patients to have their close contacts go for a thorough physical examination and regular follow-up visits.
The experts have also explained that the Bacille Calmette-Guerin (BCG) vaccination given at birth as part of the national programme on immunisation is partially protective against leprosy. There is ongoing research to develop a more specific leprosy vaccine.
Dr. Erere Otrofanowei, a consultant physician, dermatologist and genitourinary specialist with the Lagos University Teaching Hospital (LUTH), described leprosy as a chronic, infectious disease caused by an acid-fast, rod shaped bacillus mycobacterium leprae.
She said: “Leprosy is an old disease that has been present since biblical times. The patients usually have reduced quality of life, due to the stigma attached to the disease, as well as the physical symptoms. Early detection and proper management can, however, prevent lasting debilitating sequelae and reduce the impact of disease on the patient and the community.
“Though the disease is not confined to any particular race, it occurs more in the tropics. Nigeria is one of the five countries, where leprosy is still considered endemic alongside India, Brazil, Indonesia and Bangladesh. This status, however, fluctuates from year to year, probably because the health records are not well updated.
“Despite achieving the elimination target of less than one case detection per 10,000 population, as stated by the World Health Organisation (WHO), in the year 2000, there are still pockets or clusters of leprosy with high endemic rates in different parts of the country.
“New cases of leprosy are still being recorded in our hospitals today, and it is unfortunate that most patients present the late stages of the disease. This is largely due to ignorance and the stigma attached to the disease, which prevents patients from coming forward, as well as failure to detect the disease early. It is important for the public to know that both male and female can contract leprosy, and it can occur at any age though rare in infants.”
Otrofanowei explained that contrary to some myths, the disease is not as a result of “home trouble” or “juju” as many people tend to believe. The organism that causes the disease divides slowly, and it takes a long time for anyone who has contracted the mycobacterium to actually come down with it. This is referred to as the incubation period, which ranges from a few months to almost 40 years with an average of about 10 years.
“The disease is most likely transmitted by the respiratory system, through nasal droppings from untreated persons,” she said. “It may also enter the blood stream through broken skin. Whether or not a newly infected person goes on to develop the disease depends on a number of factors, including the immune status, the type of leprosy contracted, whether paucibacillary or multibacillary, the patient’s age, some genetic factors and the likes.
“Generally, most people don’t develop the disease, following exposure to the organism. Paucibacillary and Multibacillary leprosy are WHO’s classification of the disease, which employs such simple measures as the presence of skin lesions and detection of bacilli in skin smears to determine what arm of treatment a patient should have. It is mostly used to stratify patients in developing countries, where there may be a dearth of specialists.
“The leprosy elimination programmes across the country would do well to ensure harmonisation of all stakeholders’ efforts in the industry at all levels of healthcare delivery.”
She implored the public to get well informed about the disease via different media and wherever the information is in the public domain for the benefit of the masses, as information and the right application is power. And if possible, leprosy should be separated from tuberculosis in the NTBLCP, as it is cast aside in favour of its bigger competitor for resources. All hands must be on deck to ensure that Nigeria achieves and sustains WHO’s leprosy elimination target.
She said: “This would lead to increased awareness of the disease, early presentation and effective management with the added measure of reduced stigmatisation.
“Mycobacterium leprae primarily, targets the skin and peripheral nerves of the body. The earliest symptom of Hansen’s disease is a well-demarcated, discoloured skin patch or blemish with reduced or no sensation. Thus, an individual with few innocuous pale or light-coloured skin patches one to five in number, who cannot feel cold or hot sensation, or touch at those specific spots, needs to have them checked out further by a doctor. Likewise, the absence of sweating at those specific patches is a sign to investigate further.
“The above suggests paucibacillary leprosy, where there are five or fewer skin lesions with undetectable bacteria in skin smears and this type or stage of the disease is where treatment is most effective. Sadly, this is the disease that is mostly missed or overlooked by both individuals and even some healthcare professionals, allowing a progression to multibacillary leprosy, with more than five skin lesions and bacteria easily detected in skin smears, where the more recognisable features occur.
“These signs and symptoms include, multiple swellings or lumps along the earlobes, nose, face paraesthesia tingling or numbness in the hands or feet, enlarged or thickened painful peripheral nerves at the elbow, behind the ears, behind the knees, painless wounds or burns, and later, such signs as loss of fingers and toes, blindness, loss of eyebrows and eyelashes, weakness of the hands and claw-like fingers and collapsed bridge of the nose to name a few, are seen in advanced stages of the disease and are indeed the result of a failed health care system.”
Otrofanowei stated that certainly, leprosy has public health hazards, as enumerated above with respect to the mode of transmission and the resulting clinical features. Hansen’s disease is still considered one of the neglected tropical diseases (NTD), as the impact of the disease to patient, care givers and country is grave.
“In some parts of the world, the stigma of the disease isolates the patient, promotes mental health disease and even suicidal ideation,” she explained. “In suspected case of Hansen’s disease, the next step is to present oneself to a healthcare professional at primary, secondary or tertiary centres. A detailed clinical history and physical examination will be carried out and some investigations ordered, including some blood tests, skin slit and smears to detect the acid-fast bacilli or a skin biopsy.”
Dr. Chukwuma Ogunbor, a consultant family physician and Chief Operations Officer with Cedar Group Hospital, Festac Town, Lagos, said the treatment of leprosy is effective with a combination of medicines for a specified period.
He said: “Drugs for Hansen’s disease may be two drugs of rifampicin and dapsone at weight-based doses for paucibacillary leprosy or three drugs with clofazimine added to the above two. Some of the drugs are to be taken daily, while some are taken monthly. After taking only a few doses of the medication, patients become non- infectious. Hence, there is no need to isolate them from family and friends.
“There are a few sophisticated tests like polymerase chain reaction and serology, which may be employed in doubtful cases. Some hospitals may not be well equipped to do a few of the above and the patient may need referral to any of the teaching hospitals in the country for further management by a specialist.
“The duration of treatment is determined by the disease classification, but the drugs are usually taken for about 12 months or more. It is laudable that patients with Hansen’s disease can get their drugs for free at designated national leprosy control centres in all the 36 states of the country, as well as the Federal Capital Territory.
“This is a result of the national tuberculosis and leprosy control programme (NTBLCP) of the Federal Ministry of Health, which became operational in 1991.
“It is important to complete medications for as long as prescribed, as poor drug adherence can contribute to drug resistance, causing a need to move patients from the above first line therapy to a second line or alternative therapy. Sometimes, patients may develop some immunologic leprae reactions during treatment of leprosy that may require additional drugs such as corticosteroids.”