2. TOPIC LEPROSY AS AN ENVIRONMENTAL DISEASE

3. PRESENTER Relindis K Fofung PUBH-8165-10 Environmental Health Service Learning Project Walden University October, 2010 Professor: Dr. Raymond Thron

4. 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

5. INTRODUCTION - LEPROSY Called Hansens 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.National Hansen's Disease treatment

6. HISTORY OF LEPROSY Referred to in Biblical literature Historically documented since 600 BC (WHO-LEPROSY) (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.Hansen, Gerhard, A. First pharmaceutical drug was dapsone in 1940s

7. 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)

8. Some Neglected Tropical Diseases Chagas disease, Schistosomiasis, Filariasis, Buruli ulcer, Dengue Fever, Dracunculiasis (guinea-worm disease) Trypanosomiasis) (WHO NTD) (WHO NTD)

9. LEPROSY ETIOLOGY & TRANSMISSION Caused by M. leprae (WHO NTD)WHO NTD Respiratory droplets transmission From person to person From enzootic animal to human Incubation period of 3 to 40 years

10. Mycobacterium leprae close "cousins M. tuberculosis M. ulcerans M. intracellulare M. avium M. xenopi M. simiae M. kansasii

11. 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)

12. SYMMETRICAL RASH ARM & TORSO

13. FEW RED LEPROSY BLOTCHES

14. ARM AND ELBOW INVOLVEMENT

15. DEFORMED DIGITS

16. SYMMETRICAL LEPROSY RASH ON LEGS

17. ARM WITH LEPROSY RASH

18. LEPROSY INFECTED EYE

19. KNEE INVOLVEMENT

20. DRY AND SCALY LEPROSY SKIN

21. DRY SCALY LEPROSY SKIN

22. LEPROMATOUS EAR LOBE

24. VASCULITIC ULCERATIONS-LUCIO PHENOMENON See more at Fatal Lucio phenomenon This resemble buruli ulcerburuli ulcer

25. 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.WHO – Diagnosis of Leprosy.

26. REASONS FOR LATE DIAGNOSIS Social stigma due to disfiguration Inability to grow M. leprae in Laboratories Symptoms Resemble other diseases Many Doctors have little experience in the disease (Nature Reviews)little experience Most US Physicians are untrained to diagnose leprosy References: 1. Nature Reviews. Neurology. Nerve damage in leprosy and its management.

27. CONTRIBUTING FACTORS IN THE AMERICAS LEPROSY Genetics disposition Environmental conditions. Low literacy level Malnutrition Poverty, per Oxford Journalper Oxford Journal Exposure to nine banded armadillo (Truman, NIH, 2005) (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.

28. INDIGENOUS CASES OF NON-HUMAN ETIOLOGY LEPROSY Texas armadillo hunter develops Leprosy (Becker, Kowalewski, & Martin IV,2009). (Becker, Kowalewski, & Martin IV,2009). Brazil two fold increase leprosy incidence with armadillo exposure (Deps, Alves, Gripp, Aragao & Guedes, 2008 ) (Deps, Alves, Gripp, Aragao & Guedes, 2008 ) Indigenous US lepers (Dr. Franco-Paredes and ABC News) (Dr. Franco-Paredes and ABC News) References: 1. Becker, L., Kowalewski, C., & Martin IV, J. (2009). Nonpruritic erythematous plaques. Journal of Family Practice, vol. 58 pp. 657-659 2. Deps, P., Alves, B., Gripp, C., Aragao, R.,and Guedes, 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

29. 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) 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 (Dasypus novemcinctus) from the And. Retrean region of Colombia. Leprosy Review, vol. 80,pp. 424-431 2. Becker, L., Kowalewski, C., & Martin IV, J. (2009). Nonpruritic erythematous plaques. Journal of Family Practice, vol. 58 pp. 657-659

30. ENZOOTIC LEPROSY-ARMADILLO cont Other M. leprae reservoirs are: Chimpanzees and mangabey monkeys (NIH)(NIH) Monkey to monkey transmission observed Monkey to monkey M. lepraemurium causes cat and mice leprosycat and mice leprosy Mice develop nerve damage but not cats Cat leprosy leproma look like humansleproma M. lepraemurium is a non-human pathogen

31. ARMADILLO

33. 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:

34. FACIAL AND HAND DEFORMITIES

35. 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-WER, 2009) WHO. Weekly Epidemiological Report (WER). 14 august 2009, No. 33

36. 2008 NEW CASE FROM COUNTRIES REPORTING MORE THAN 1000 CASES

37. WHO:NEW CASES REGIONAL DATA

38. LEPROSY IN THE AMERICAS 1978 to 1985 Indochinese refugee to USA US epidemic peaked in 1985 But declined in 1988 (Mastro, Redd & Breiman, 1992) (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) (WHO, WER, 2009) High incidence due to environmental and social behaviors (Kerr-Pontes, Barreto, Evangelista, Rodrigues, Heukelbach, & Feldmeier, 2006) (Kerr-Pontes, Barreto, Evangelista, Rodrigues, Heukelbach, & Feldmeier, 2006)

39. 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)

40. 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 Hansens 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.

41. ELIMINATION STRATEGIES Surveillance and monitoring Raise awareness of signs and symptom Political commitment (WHO NTD) (WHO NTD) Identification of Risk factors (WHO-leprosy) (WHO-leprosy) Sustainable Multi drug therapy and health education Encourage and gain public trust to seek help early Ease accessibility to diagnosis (WHO NTD) (WHO NTD) Enable easy national surveillance and monitoring Discourage stigmatization through education (WHO NTD) (WHO NTD) References: 1. WHO Neglected Tropical Diseases (NTD). 2. WHO-Leprosy. Retrieved from

42. 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) (WHO WER) Excellent Case of Sri Lanka (WHO NTD) (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 ) (WHO NTD ) References: 1. WHO. Weekly Epidemiological Report (WER). 14 august 2009, No. 33. 2. WHO Neglected Tropical Diseases (NTD).

43. REFERENCES 1 1. Becker, L., Kowalewski, C., & Martin IV, J. (2009). Nonpruritic erythematous 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 (Dasypus novemcinctus) from the And. Retrean region of Colombia. Leprosy Review, vol. 80,pp. 424-431. 3. Deps, P., Alves, B., Gripp, C., Aragao, R.,and Guedes, 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

44. 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/16248207http://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.pdfhttp://whqlibdoc.who.int/publications/2009/9789241598705_eng.pdf 13.. WHO. Weekly Epidemiological Report (WER). 14 august 2009, No. 33