Eradicating leprosy | New treatment

Lady begging with her children in Delhi. Instagram: @glennlosack

Multi-drug therapy leprosy treatment has been around for more than 35 years. The World Health Organisation and Novartis have been providing free leprosy treatment for the last 18 years and in 2016 India produced the first leprosy vaccine in an attempt to finally eradicate leprosy. Whilst the population affected with the disease is decreasing, over 200,000 new cases were diagnosed in 2015, making it seem a long way from being removed from the World Health Organisations neglected tropical diseases list.

In 2010, I had my first foray into humanitarian medicine when I visited Dayapuram Manamadurai Leprosy Mission Hospital in Southern India. With a 50-bed inpatient wing and serving over 40,000 outpatients per year, it is one of the largest facilities in Southern India. It was here that I was able to see the devastating effects this disease can have on a human. Many of the inpatients here had multiple disabilities, yet it was not just the physical manifestations of the disease causing such a burden. There is still great stigma attached to a diagnosis of leprosy.

Kalaupapa Leprosy Settlement. Instagram: @youngleprosy

A recent study, published this year, by a group of dermatologists from Lucknow hospital in North India found that 21.7% of the patients believed leprosy to be due to ‘bad blood’ and 10% believed it to be a supernatural phenomenon. This suggests that despite efforts to educate the population and remove the perceived disgrace which, historically, has accompanied a diagnosis, this has not been thorough enough.

A photo showing a woman with an above knee amputation wearing traditional hindu dress in red and green with her prosthesis next to her.
Cheanbramma in her village in Andhra Pradesh. Instagram: @ruth.towell

What is leprosy?

Leprosy is a chronic communicable disease. It is primarily spread by droplet infection of Mycobacterium Leprae. It causes infection of peripheral nerves ultimately leading to destruction from the rapid immunological response leaving a sufferer with paralysis and deformity.

The skin, mucous membranes and nerves are the most affected leaving patients with hair loss, particularly the eyebrows and eyelashes. Sufferers also get patches of pale, discoloured skin, or may develop ulcers or growths in affected areas. Nosebleeds are common in patients whose mucous membranes have been affected. The nerve damage, which ensues following infection, leads patients to leave burns and injuries unnoticed. Eventually chronic untreatable ulcers, blindness and deformities of the extremities will develop.

An image showing an elderly gentleman with wrinkled skin and leprosy lesions on his face praying
A man asking for prayers after facing many health challenges including a diagnosis of leprosy. Instagram: @crb93

Disease Prevalence

Over 60% of all leprosy sufferers live in India, however distribution is not uniform throughout the country. Despite India eliminating Leprosy from it’s list of public health problems in 2005, in some districts prevalence remains as high as 3-4 cases per 10,000 people. Much greater than the 1 per 10,000 criteria in order to meet the elimination criteria. Additionally, the annual detection rate is nearing 1 in 10,000 suggesting that a greater effort may be needed going forward in order for it to remain off the list.

Over 60% of all leprosy suffers live in India; In 2015 >127000 new diagnoses were from India out of a global total of just under 211,000. Stigma, lack of awareness and lack of access to medical treatment could mean this number of cases is in fact higher. This includes inadequate knowledge from medical professionals themselves. As demonstrated in a study undertaken in 2017 at Rajarajeswari Medical College in India. This study found that only 38.15% of final year medical students were able to identify the main signs and symptoms of leprosy, with other 30% failing to recognise the signs of neuritis.

In the UK, leprosy still seems a fairly removed disease from our everyday life, however, it may surprise many of you that there were over 135 cases diagnosed in the UK since 2003. Whilst that may not seem significant, the annual number of new diagnoses globally remains above 210,000.

a photo showing an ethiopian woman with amputated fingers following leprosy infection. she is sat down wearing tradition dress, smiling
Leprosy colony, Addis Ababa/Ethiopia, 2013. Instagram: @ourlives0420

Leprosy Treatment

At the time of my visit to a Leprosy hospital in Southern India, there had already been a huge push to de-marginalise lepers and reintroduce them to communities. However, leprosy hospitals were still common place and it was at these institutions that patients would get the most thorough and holistic care.

Dayapuram Manamadurai Leprosy Mission Hospital was set in beautiful grounds and had very attentive staff. The mainstay of leprosy treatment here was supportive as many of the patients already had significant neuropathy and disfigurement. Foot care was essential and patients were taught how to inspect for skin tears, breaks and ulcers. Eye care was extremely important and the hospital had good links with ophthalmologists who could perform sight saving surgery if necessary. Each patient received a district rehabilitation officer upon discharge in order to reintegrate them into society following a long stay.

Multi-Drug Leprosy Treatment

The introduction of multi-drug therapy made a significant impact on the success of leprosy treatment. The World health Organisation made it free for all leprosy patients in endemic countries in 1995. It involves concomitant leprosy treatment with rifampicin, clofazimine and dapsone. Solo drug therapy will almost always lead to drug resistance. Since it’s introduction, the treatment now reaches almost 100% of the global need and includes free laboratory testing courtesy of Novartis for new cases.

Despite efforts, detection of new cases of leprosy remained fairly stable and a new reinvigorated strategy was released from the WHO in 2016. The new initiative aims to increase detection of the disease in at risk groups before disability occurs. It also helps to aid detection by increasing education in marginalised communities.

Leprosy Vaccine

Also in 2016, a vaccine for leprosy, developed solely by the Indian National Institute of Immunology was piloted in 6 Indian districts. The vaccine itself contains an autoclaved suspension of mycobacterium indicus pranii (MIP) and rifampicin. Patients with confirmed leprosy infection will receive the vaccine alongside existing leprosy treatment: Multi-drug therapy.

MIP not only shares antigens with M. Leprae, it also has some antigens of M.Tuberculosis and has been used successfully to aid treatment in treatment-resistant TB cases.

So far the vaccine is believed to aid bacterial clearance and shorten the recovery time of patients infected. It also successfully vaccinates healthy patients, with over 98% having initial lepromin positive status following vaccination. Large scale field studies carried out in a rural Indian population saw 24,000 close contacts of leprosy patients be vaccinated with the MIP vaccine. Of those involved in the study, 68.6% were lepromin positive at 4 years and 59% at eight years.

 

Diagrams showing leprosy patients with mulitple skin lesions and comparisons of less lesions after treatment with leprosy vaccine and multidrug therapy
Some representative cases of LL/BL multibacillary patients treated with MDT plus MIP – Talwar GP, Gupta JC (2017)

A clinical trial is being carried out with three treatment arms: rifampicin alone, rifampicin plus MIP vaccine and the vaccine alone. Vaccine boosters will be given at two and five years. Close contacts and relatives of leprosy sufferers will be identified as subjects. If the trial shows MIP to be successful at reducing infection of M.Leprae it will be rolled out as a national vaccination programme.

A successful trial could mean leprosy may be finally eradicated as a health problem in India and perhaps even globally within the next 10-15 years. Let us act on our past mistakes and not take our foot off the accelerator until we have achieved this aim.

Lymphatic Filariasis is another infectious disease on the World Health organisations list for targeted eradication. Read more about the success stories here.


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