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TOPIC. LEPROSY AS AN ENVIRONMENTAL DISEASE. PRESENTER. Relindis K Fofung PUBH-8165-10 Environmental Health Service Learning Project Walden University

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topic
TOPIC

LEPROSY AS AN ENVIRONMENTAL DISEASE

presenter
PRESENTER

Relindis K Fofung

PUBH-8165-10

Environmental Health

Service Learning Project

Walden University

October, 2010

Professor: Dr. Raymond Thron

outline
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
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
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
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
Some Neglected Tropical Diseases
  • Chagas disease ,
  • Schistosomiasis,
  • Filariasis,
  • Buruli ulcer,
  • Dengue Fever,
  • Dracunculiasis (guinea-worm disease)
  • Trypanosomiasis) (WHO NTD)
leprosy etiology transmission
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
Mycobacterium lepraeclose "cousins”
  • M. tuberculosis
  • M. ulcerans
  • M. intracellulare
  • M. avium
  • M. xenopi
  • M. simiae
  • M. kansasii
types of leprosy and symptoms
TYPES OF LEPROSY AND SYMPTOMS
  • Tuberculoid or paucibacillary

- Mild form of Leprosy

- One or more light skin-blotches

  • Lepromatous

- Multibacillary

- Symmetrical rash

- Widespread

(WHO – Leprosy)

vasculitic ulcerations lucio phenomenon
VASCULITIC ULCERATIONS-LUCIO PHENOMENON
  • See more at

Fatal Lucio phenomenon

This resemble buruli ulcer

diagnosis methods
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
REASONS FOR LATE DIAGNOSIS
  • Social stigma due to disfiguration
  • Inability to grow M. leprae in Laboratories
  • Symptoms Resemble other diseases
  • Many Doctors have little experiencein 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
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
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:

  • Becker, L., Kowalewski, C., & Martin IV, J. (2009). Nonpruriticerythematous plaques. Journal of Family Practice, vol. 58 pp. 657-659
  • Deps, P., Alves, B., Gripp, C., Aragao, R.,andGuedes, 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
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 (Dasypusnovemcinctus) from the And. Retrean region of Colombia. Leprosy Review, vol. 80,pp. 424-431

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

enzootic leprosy armadillo cont
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

Oops, busted!

Oh, lovable Dinosaur-looking me!

armadillo1
ARMADILLO

What about my beautiful toes?

morbidties from leprosy
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:
current global statistics
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

leprosy in the americas
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
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
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
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:

  • WHO Neglected Tropical Diseases (NTD).
  • WHO-Leprosy. Retrieved from
elimination in progress
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:

  • WHO. Weekly Epidemiological Report (WER). 14 august 2009, No. 33 .
  • WHO Neglected Tropical Diseases (NTD).
references 1
REFERENCES 1

1. Becker, L., Kowalewski, C., & Martin IV, J. (2009). Nonpruriticerythematous 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 (Dasypusnovemcinctus) from the And. Retrean region of Colombia. Leprosy Review, vol. 80,pp. 424-431.

3. Deps, P., Alves, B., Gripp, C., Aragao, R.,andGuedes, 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
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

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