ORIGINAL RESEARCH ARTICLE. Access this Article Online. Website: Subject: Medical Sciences

Transcription

1 International Journal of Current Medical And Applied Sciences, 201, November, (3),1-. ORIGINAL RESEARCH ARTICLE Clinico-Epidemiological Trends of Leprosy in post Elimination Period at an Urban Leprosy Clinic of a Tertiary Care Hospital: A Retrospective Study of Six Years. Rama M Cheedirala 1, T V Narasimha rao 2, Sowmya Srirama 3*, Swarna K Gunupudi 4 & Nageswaramma Siddhabathuni 1 Assistant Professor, 2 Associate professor, Senior Resident 3*, 4 Associate professor, Head of Department & Professor, Department of Dermatology, Venereology & Leprosy, Guntur Medical College, Guntur. * Rajiv Gandhi Institute of Medical Sciences, Ongole, Andhra Pradesh, India Abstract: Background: India has achieved goal of elimination of leprosy (Prevalence Rate < 1 per 10,000 population) by December 200, but still significant number of new cases are being reported. Aims: The present study was done to evaluate epidemiological and clinical profile of leprosy patients and to assess the changing trends, if any in post elimination period. Methods: This retrospective study included newly registered patients at Urban Leprosy Centre(ULC) attached to the department of Dermatology, Venereology & Leprosy from January 200 to December 2012 i.e., for six years. Year wise data was analysed according to age, sex, geographic area, clinical spectrum, reactions and deformities. Statistical tools like Chi-square test and Fisher s exact T test were used, percentages and ratios were computed wherever necessary Results: 6 patients (61% Males, 39% Females, 4% urban & % rural) were registered during this period. There was statistically significant decrease in the number of new cases registered from 200(12) to 2012(9). Most common age group involved was Year (26.0%) and spectrum was Boderline tuberculoid (4.6%). Multi bacillary (MB) cases increased over study period i.e., 200(33.6%) to 2012(4.3%). Grade -1 deformities were 10.3%, Grade-2 deformities 13.4%, type 1 reaction in 2.% and type 2 reaction in 3.% of new patients respectively. Conclusions: Increase in number of MB cases suggests an active infection in the community. This may warrant future resurgence of leprosy as a serious health problem as seen with other infectious diseases such as malaria and tuberculosis, so we should not be complacent at this stage. Key-Words: Elimination, Epidemiology, Leprosy, Multi bacillary, Trends of leprosy. Introduction: Leprosy is a chronic infectious disease and has affected humanity for over 4000 years. The global burden of leprosy has decreased over the past 0 years and India has played a major role in this decline, the credit for which is attributable to the National Leprosy Elimination Programme (NLEP) [1]. With the introduction of MDT(Multi Drug Therapy) our country has achieved the goal of elimination in December 200 with Prevalence Rate(PR) of 0.9/10,000 population [2]. Address for correspondence: Dr. Sowmya Srirama. Post-graduate Student, Dermatology, Venereology & Leprosy Rajiv Gandhi Institute of Medical Sciences, Ongole, Andhra Pradesh, India. sowmee.134@gmail.com How to cite this article: Rama M Cheedirala, T V Narasimha rao, Sowmya Srirama et al Clinico- Epidemiological Trends of Leprosy in post Elimination Period at an Urban Leprosy Clinic of A Tertiary Care Hospital: A Retrospective Study of Six Years. International Journal of current Medical and Applied sciences; 201, (3), 1-.. Access this Article Online Quick Response Code Website: Subject: Medical Sciences IJCMAAS,E-ISSN: ,P-ISSN: Page 1

2 Rama M Cheedirala, T V Narasimhaa rao, Sowmya Srirama, Swarna K Gunupudi & Nageswaramma Siddhabathuni Though the target of leprosy elimination was achieved, a large proportion of cases still come from India[1]. In 2012, 219,0 new cases were reported globally, out of them 12,29 (.1%) were detected in India[1]. Many reasons have been attributed to the decline in registered prevalence, like decentralization of NLEP, shortening of treatment duration and cleaning of the registers. Taking into consideration of above scenario the present study was done to evaluate the clinical and epidemiological data and changing trends of leprosy in post elimination period at Urban Leprosy Clinic(ULC) attached to tertiary care hospital. Materials and Methods: department of DVL, so the centre has records of all leprosy cases attending the clinic. Being a referral centre many leprosy patients directly attend and are referred to it from surrounding villages and districts. A detailed clinical history was taken, clinical examination was done with slit skin smear and histopathological examination as supplements for the diagnosis and classification of leprosy. The patients were classified according to Ridley-Jopling and WHO classifications. The epidemiological and demographic data of newly registered patients at the urban leprosy centre during 200 to 2012 were analyzed to observe the various epidemiological trends. The extracted data from the records was analysed into Microsoft Excel A retrospective analysis of the recorded data of spread sheet 200. Statistical tools like Chi-square leprosy patients attending ULC in Department of test and Fisher s exact T test were used, Dermatology, Venereology & Leprosy at a referral percentages and ratios were computed wherever hospital from January 200 to December 2012 ie., necessary. for six years was done. The ULC was attached to Results: Table 1 : Age wise distribution of cases Year Age groups (years) & above A total of 6 new patients attended the ULC during the study period of six years ( ). The number of new cases registered decreased from 12 in 200 to 9 in 2012 which was highly statistically significant (P=0.000). Males(413) outnumbered females (262) with a ratio of 1.6 : 1, the year wise proportions of male cases among new cases was more than females (Figure-1). Majority of patients were in age group of years (26.0%) followed by years (16.%) and children constituted about 12.46% (Table-1). Table 2 : Year wise distribution of percentages of individual type of leprosy patients with no. of patients in the brackets Year IND TT BT BB BL LL PN %(1) 2.36%(3) 62.20%(9) %(2) 3.41%(4).9%(69) 1.44%(2) 1.4%(2) 63.6%() 0.91%(1) 3.66%(4).04%(60) 1.12%(1).61%() 1.6%(46) %(1) 4.21%(4) 44.21%(42) 6.29%() 14.96%(19).12%(6) 1.9%(21) 2.90%(4) 16.66%(23) 3.6%(4) 1.43%(19) 4.49%(4) 16.%(1) 4.21%(4) 1.90%(1) 6.29%() 4.2%().9%(11) 6.42%() 13.4%( (12) 14.3%( (14).0%(9).4%(10).9%() 12.4%(14) 6.4%(6) 13.6%(13) IND: Indeterminate; TT: Tuberculoid; BT: Borderline Tuberculoid ; BB:Mid Borderline; BL: Borderline Lepromatous; LL: Lepromatous leprosy ;PN: Pure Neuritic. Percentage of number of new patients in each spectrum with number of new patients in the brackets. Figure 1: Year wise percentage of male and female cases Year wise percentage of male and female patients 66.63% 64.11% 66.06% 6.1%.9% 3.69% 46.31% 39.3% 3.9% 42.02% 33.94% 34.3% Logic 201, IJCMAAS, E-ISSN: ,P-ISSN: Page 2

3 Logic 201, IJCMAAS, E-ISSN: E ,P-ISSN: Figure 2:: Year wise percentages of PB & MB cases (P = 0.04). 0.00% 0.00% 60.00% 0.00% 40.00% 30.00% 20.00% 10.00% 0.00% PB MB PB 66.14% 6% 6.40% 9.30% 9.% 2.63% MB 33.6% 3% 32.60% 40.0% 40.4% 4.3% Most of the patients hailed from rural area (rural 33, urban -302). 302). The proportion of multi bacillary(mb) cases among new cases has increased from 33.6% in 200 to 4.3% in This This increase in the proportion of MB cases was found to be statistically significant (P = 0.04) (Figure-2). Table Year wise percentage of lepra reactions Table-3: Year Type-1.%.9% 6.2%.34% 6.4% 6.31% Type %.69%.9% 6.42%.6%.42% Borderline Tuberculoid (BT) - 6.9% (34) was the most common type followed by Borderline Lepromatous (BL) - 16.%(114) (Table-2). 2). Lepromatous Leprosy(LL) constituted about.4%() of total patients of which four of them had histoid type of lesions. A total of 96 new patients(14.3%) presented with either type 1 or type 2 lepra reactions of them typetype 1 was 4.9%( 4) & type- 2 was 1.04% (49) (Table (Table-3). Table-4 : Year wise deformities of the study subjects Grade-1 Grade -2 Year wise percentage of Hands Legs Year deformities percentage percentage Hands Legs of Grade--1 defromities Claw Foot Trophic of Grade-2 deformities hand drop ulcers % % 22.04% % % 1.0% 9.42% 0 10.% 20.29% % % 33.4% % % 26.96% % % 21.09% A total of 23.%(161) of patients presented with deformities of which Grade-1 Grade 1 deformities were 10.3%(0) and Grade-2 2 deformities were 13.4% (91) patients (Table-4). (Table Figure 3 : Year wise percentage of children and adults Children % Adult 9.9% 14.60% 1.4%.40% 1.3% 14.04% %.96% %.4%.40% International Journal of Current Medical And Applied Sciences Science [IJCMAAS], Volume :, Issue: 3 3.

4 Rama M Cheedirala, T V Narasimha rao, Sowmya Srirama, Swarna K Gunupudi & Nageswaramma Siddhabathuni Discussion: Leprosy is a chronic infectious disease caused by Mycobacterium leprae, affecting peripheral nerves, skin and certain other tissues. It is characterised by a spectrum of mild hypopigmented patch to hypo anaesthetic patches, peripheral nerve thickness, lepra reactions, anaesthesia, deformities, disabilities and death in few due to systemic complications and reactions. The goal of elimination of leprosy, as a public health problem was reached at global level in the year 2000 [3]. This was followed by the Strategic Plan for Leprosy Elimination through which India achieved elimination on 31st December, 200. Global Strategy for Further Reducing the Leprosy Burden and Sustaining Leprosy Control Activities was pioneered with the main intention of ensuring program sustainability by reducing reliance on vertical infrastructure and promoting integration within the General Health Care System(GHS) [3]. The Enhanced global strategy for further reducing the disease burden due to Leprosy: -201 also focuses on sustaining the gains made so far [4,]. We have made an attempt to analyze data of ULC attached to our hospital from to find out impact of integration into GHS in the post elimination period. This retrospective study of 6 new leprosy patients who attended the ULC revealed that the total number of new cases recorded declined from 12 in 200 to 9 in 2012, which was highly statistically significant (P=0.000). Similar trend was reported at an ULC in Delhi [6] and in Jamnagar district of Gujarat [] and consistent with NLEP progress reports []. This decline in the number of new cases may be attributed to integration of NLEP into GHS and the efforts of NLEP. The proportion of male patients affected by leprosy is comparatively more than female patients, similar to other studies by Tiwary et al [6], Sanghavi [] and NLEP progress reports []. Females patients are less in number when compared to males, as males frequently self-report to hospitals for treatment, it is a general pattern in India. The number of new cases among females and children didn t have any pattern over these six years. BT hansens was the most common type in the leprosy spectrum. The proportion of patients in borderline spectrum(bt,bb,bl) are more when compared to other spectra. The early detection of single lesions of tuberculoid stage can be easily missed and it is of least concern in patients of low socioeconomic status. So all these may degrade which could be a cause for detection of large proportion of patients in borderline spectrum. There is rise in the proportion of LL hansens in and There is a rise in the percentage of MB cases from (40.%, 40.4%,4.3%) compared to previous years 200-(33.6%, 3%, 32.6%) similar to NLEP progress reports [-14]. Increase in MB cases indicates delay in diagnosis. The following can be one of the reasons for increase in MB cases : 1) The early hypopigmented patches which are not anaestheic or not too many in number don t pose a problem for the patients as they don t hinder the daily activities except for cosmetic concern. So these patients turn out at the hospitals in the late stages of disease, as multibacillary forms, in lepra reactions, with deformities and disability.2) In preelimination era, NLEP had active surveillances like door to door surveys by trained and experienced workers of vertical programme who treated patients at early stages of disease activity. In post-elimination era with the shifting of vertical programme to PHC personnal who have little experience in diagnosing leprosy, may be a cause for more percentage of multibacillary cases. 3) The treatment duration had been constantly being revised from two consecutive skin smear negative results in 191, 2 years of Fixed duration Therapy (FDT) in 1992 to 1 year of FDT in 199. Slit skin smear examination at the end of treatment was not mandatory. So this one year of treatment may not be sufficient as the treated patients may still serve as sources for infection. No consistent trend was observed in the presentation of lepra reactions in the study period. A consistent trend was not observed in deformities. On consolidating our study we found that NLEP and other enhanced strategies for sustaining the gains made so far were making an impressive impact on leprosy status and elimination of leprosy level has been maintained. But increase in MB cases(esp LL) suggests that there is an active infection in the community. These cases serve as potential sources of disease harbouring many bacilli and might have transmitted disease to others(especially household contacts) long before their disease becomes clinically detectable [1]. This may warrant future resurgence of leprosy as a serious health problem as seen with other infectious diseases such as malaria and tuberculosis [16]. As leprosy has got long incubation period and persistent course we should not be complacent at this stage. Sustained efforts must be continued and resources made available to achieve a world without leprosy. References: 1. Dogra S, Narang T, Kumar B. Leprosy evolution of the path to eradication. Indian J Med Res 2013;13: NLEP, Deputy Director General (Lep.) Directorate General of Health and Family Welfare, Govt. Of India. Available from: [last cited on 2013 Oct 14] 3. World Health Organisation. Fact sheets on leprosy N 101 [updated 2014 Jan]. Available from : Logic 201, IJCMAAS, E-ISSN: ,P-ISSN: Page 4

5 Logic 201, IJCMAAS, E-ISSN: ,P-ISSN: WHO/SEARO. Regional strategy for sustaining leprosy services and further reducing the burden of leprosy SEA-LEP-162. ;1-21. World Health Organisation. Global Leprosy situation, Wkly Epidemiol Rec 2012;: Tiwary PK, Kar HK, Sharma PK, Gautham RK, Arora TC, Naik H et al. Epidemiological trends of leprosy in an urban leprosy centre of Delhi : A retrospective study of 16 years. Indian J Lepr, ;3: Sanghavi MM. A review of trend of leprosy situation in Jamnagar district of Gujarat. Natl J Community Med 2012;3: NLEP progress reports for the years ending on 31 st march Central leprosy 9. NLEP progress reports for the years ending on 31 st march 200. Central leprosy 10. NLEP progress reports for the years 200- ending on 31 st march. Central leprosy 11. NLEP progress reports for the years - ending on 31 st march. Central leprosy 12. NLEP progress reports for the years - ending on 31 st march. Central leprosy [ last cited on October ]. 13. NLEP progress reports for the years ending on 31 st march Central leprosy 14. Vijayakumaran P, Prasad B, Krishnamurthy P. Trends in new case-detection leprosy in Bihar, India. Indian J Lepr 2006;: Singal A, Sonthalia S. Leprosy in post elimination era in India: Difficult journey ahead. Indian J Dermatol 2013;: Rao PN, Lakshmi TS. Final push of leprosy in India : What is being pushed? Indian J Dermatol Venereol Leprol 200;1: Conflict of interest: No source of funding. None declared. International Journal of Current Medical And Applied Sciences [IJCMAAS], Volume :, Issue: 3.