Otrofanowei: Leprosy and how to deal with it

Dr. Erere Otrofanowei is a Consultant physician, dermatologist and genitourinary specialist with the Lagos University Teaching Hospital. As the World marks Leprosy Day tomorrow, she spoke on prevention, treatment and management of the disease in this Interview with Paul Adunwoke

What is leprosy?
Leprosy is a chronic infectious disease caused by an acid-fast, rod-shaped bacillus mycobacterium leprae. It is an old disease that has been present since Biblical times. The patients have a 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 the disease on the patient and the country at large.

What should the public know about leprosy?
The disease is not specific to any particular race, but is seen 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 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 at the late stages of the disease. This is largely due to ignorance, the stigma attached to the disease, which prevents patients from coming forward and failure to detect early disease. 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.

Contrary to some myths, it is not a result of “home trouble” or “juju,” as many people may think. 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 the disease. This is referred to as the incubation period and it 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 with disease. 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 of the person, the type of leprosy being contracted, whether paucibacillary or multibacillary, the age of the patient, some genetic factors and the likes.

Generally, most people do not develop the disease following exposure to the organism. Paucibacillary and multibacillary leprosy are WHO classification of the disease, which employs 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.

What are the signs and symptoms people should watch out for?
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 it checked out further by a doctor.

Likewise, absence of sweating at those specific light coloured 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 the 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. Later, signs such as loss of digits fingers and toes, blindness, loss of eyebrows and eyelashes, weakness of the hands and claw fingers, 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.

Does leprosy have public health hazards?
Certainly, it 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 its impact on patient, care givers and country is grave.

In some parts of the world, the stigma of the disease is isolation of the patient; promotion of mental health disease and even suicidal inclination.

What is the next step to take after noticing symptoms?
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.

There are a few sophisticated tests, such as 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.

How should leprosy be treated?
Treatment is effective with a combination of medicines for a specified period. 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 two above. 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.

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 (FCT).

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, because poor drug adherence can contribute to drug resistance, causing a need to move patients from the above first line of 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.

How can it be avoided and prevented?
Prevention of the disease is centred on public health education to curb ignorance of the disease, clinical management of active cases, as well as management of contacts. The teaching is that any patient confirmed to have leprosy should have his or her close contacts attend the clinic for a thorough physical examination and regular follow up visits.

Vaccination with the Bacille Calmette-Guerin (BCG) given at birth, as part of our National Programme on Immunisation is also partially protective against leprosy. There is ongoing research to developing a more specific leprosy vaccine.

What is your advice for all?
I would implore everyone to get well informed about the disease via different media, such as this interview, where the information is in the public domain for the benefits of the masses. Information and the right application of the knowledge garnered is power.