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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 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 lepraeclose "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-blotches • Lepromatous - Multibacillary - Symmetrical rash - Widespread (WHO – Leprosy)
VASCULITIC ULCERATIONS-LUCIO PHENOMENON • See more at Fatal 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 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 • 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: • 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 • 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 • 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 Oops, busted! Oh, lovable Dinosaur-looking me!
ARMADILLO What about my beautiful toes?
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 • 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 • 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: • WHO Neglected Tropical Diseases (NTD). • 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: • WHO. Weekly Epidemiological Report (WER). 14 august 2009, No. 33 . • WHO Neglected Tropical Diseases (NTD).
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 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