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High rate of childhood leprosy and transmission in Anuradhapura: Study

26 Apr 2022

  • Researchers recommend contact tracing and training medical officers
BY Ruwan Laknath Jayakody There is a high rate of childhood leprosy and transmission seen in Anuradhapura while more than one fourth of a family member has a contact history showing that leprosy is still spreading, a local study found. Therefore, leprosy contacts should be traced in order to reduce further incidence while contact management should be an essential component of leprosy control along with the training of medical officers on the diagnosis and management of leprosy. These findings and recommendations were made by H. Weerakoon and P. Bandara (attached to the Provincial Director of Health Services Office, Anuradhapura, North Central Province), H. Banduwardana and J. Warnasekara (attached to the Rajarata University’s Medicine and Allied Sciences Faculty’s Community Medicine Department), R. Ranawaka (attached to the Kalutara General Hospital),and  U.S. Kumara and N. Ariyarathna (attached to the Regional Director of Health Services Office, Anuradhapura) in a research article on the “Socio demographic factors, treatment seeking behaviours, and common clinical presentations of leprosy patients in Anuradhapura” which was published in the Anuradhapura Medical Journal 16 (1) in March, 2022. Leprosy, Weerakoon et al. explain, is a chronic, minimally contagious infection of the skin, nerves, and mucosa of the respiratory tract caused by the Mycobacterium leprae infection. According to the WHO recommendation, as mentioned in I.P. Kahawita and G.M.P. Sirimanna’s “Is leprosy being diagnosed efficiently at the primary healthcare level?”, Sri Lanka reached the elimination level in the late 1990s while in 2001, the responsibility of diagnosing and managing patients with leprosy was handed over to medical officers of health (MOH) throughout the country. The main associated factors for leprosy are living in close contact with patients who have untreated, active, multibacillary (MB) leprosy. The Anti-Leprosy Campaign in 2015 (“Central Leprosy Register”) reported 163 patients (8.24%) and that there was more than one leprosy patient in a family. N.P. Madarasingha and J.K. Senavirathne’s “A study of household contacts of children with leprosy” reported in 2011 that 33% of the index cases had positive contact within their household. The Bacillus Calmette-Guérin (BCG) vaccine is, as emphasised in C.S. Merle, S.S. Cunha, and L.C. Rodrigues’s “BCG vaccination and leprosy protection: Review of current evidence and the status of BCG in leprosy control” and the WHO’s “Global strategy for further reducing the leprosy burden and sustaining leprosy control activities: Plan period: 2006-2010”, known to have some protective effects against leprosy. The annual incidence of leprosy in Anuradhapura is around 100 patients, and the prevalence is more than one per population of 10,000, per the ministry’s Epidemiology Unit. Yet, Weerakoon et al. continue to observe a similar number of leprosy patients attending the dermatology clinic in Anuradhapura. Therefore, Weerakoon et al. carried out a descriptive cross-sectional study among leprosy patients diagnosed between 13 February 2019 and 12 February 2020, at the dermatology clinic of the Anuradhapura Teaching Hospital. All the clinically diagnosed leprosy patients were subjected to histological confirmation and histologically confirmed patients were included in the study. Each patient was interviewed using questionnaires which were drawn up to obtain data on groups of variables including the epidemiology (sex, age, occupation, monthly income, and the habitat), social awareness on leprosy, variables related to associated factors, variables related to the treatment pattern (number of medical office visits before referral to the dermatology clinic and from whom treatment was taken), and variables related to clinical aspects of leprosy patients (symptoms and signs, the duration of clinical features before the commencement of treatment, affected sites, and the number of affected sites). The study included 66 leprosy patients. The majority (56%) were males, and 50% were between 30-50 years old (the median [the middle number in a sorted, ascending or descending, list of numbers or data set] age was 41 years). This included seven (10.6%) who were less than 14 years old. Most (26%) were housewives, followed by farmers (19%). The Thambuththegama MOH area was commonly affected with leprosy more than other MOH areas (13-19%). More than one third (40%) had a monthly family income of less than Rs. 10,000. More than two thirds (45-68%) had heard about leprosy before being diagnosed with the disease. Most (44-67%) knew the causative agent of leprosy as a bacteria, and the majority of them (47-71%) knew the mode of transmission as respiratory droplets. Additionally, 60 (91%) knew that the skin was the most commonly affected organ. Nearly 18 (27%) had a previous contact history of leprosy with one affected family member. Half were referred for treatment after being seen by one medical person, and 16% warranted repeated visits. More than half were not timely referred for treatment because of the delay in seeking medical advice, and they were referred after one year of developing clinical features. The majority (49-74%) had less than five affected sites giving rise to paucibacillary (PB) leprosy and 26% of MB leprosy with a small number. Many (47%) presented with hypo-pigmented skin patches. The majority (51-77%) had sensory impairment over the lesions. A total of 12 (18%) had other diseases, especially non-communicable diseases, and no one had other dermatological conditions or identified nutritional problems. “Although leprosy control activities were started in the Dutch colonial era, Sri Lanka still reports more than 2,000 leprosy cases per year during the last two decades, including in the Anuradhapura District.”  The present study revealed that most of the associated factors are preventable, and that proper health education can minimise the disease burden. Sri Lanka remains an endemic country in terms of leprosy as 95% of the leprosy cases have been detected in 16 endemic countries, including Sri Lanka, per the Epidemiology Unit’s “Weekly Epidemiological Report” during a particular period in 2014. In the study, MB leprosy patients were reduced, and childhood leprosy patients were increased. The new case detection rate of leprosy and new cases among children remain high, indicating, according to A. Selvasekar, J. Geetha, K. Nisa, N. Manimozhi, K. Jesudassan, and P.S.S.S. Rao’s “Childhood leprosy in an endemic area”, ongoing transmission, with Selvasekar et al. adding that leprosy among children reflects the disease transmission in the community and the efficiency of the control programmes. The annual leprosy incidence in the study was 0.7 per population of 10,000, and it showed that the new case detection rate has reduced than earlier studies (The Anti Leprosy Campaign’s “Quarterly review of leprosy statistics in Sri Lanka”). The study showed male predominance over females. The incidence of childhood leprosy in high endemic areas varies from 10-40%, and the peak incidence was in the age group of 10-14 years (V.N. Sehgal and Joginder’s “Leprosy in children: Correlation of clinical histopathological, bacteriological, and immunological parameters” and P.S. Rao, A.B. Karat, V.G. Kaliperumal and S. Karat’s “Transmission of leprosy within households”). The study showed a childhood leprosy rate of 10.6%, and it was less than R. Ranawaka and H.S. Weerakoon’s “Childhood leprosy: Three years’ experience from the Anuradhapura District: A hospital-based study”, which showed a childhood leprosy rate of 12.1%. The study sample had satisfactory knowledge about leprosy. Ranawaka and Weerakoon showed a 45.4% contact history. Leprosy transmission within households has been identified in N. Vara’s “Profile of new cases of childhood leprosy in a hospital setting” and K. Jesudasan, D. Bradley, P.G. Smith, and M. Christian’s “Incidence rates of leprosy among household contacts of ‘primary cases’”. Good case finding and treatment with multidrug therapy with good coverage of BCG immunization in neonates would lead to a diminution of leprosy transmission and a decline in the incidence of leprosy, Weerakoon et al. elaborated. A total of one fifth of leprosy patients who had no BCG scar in the study may indicate, Weerakoon et al. add, protection from the BCG vaccination. The MB type, per Selvasekar et al., indicates the high risk of transmission. The less number of MB cases in the instant study, explained Weerakoon et al., showed that the ongoing transmission of leprosy seems to be reduced. A total of 16% warranting repeated consultation by medical officers may be due to, Weerakoon et al. observe, a lack of knowledge among the medical officers. The diagnosis of leprosy has been missed on several occasions. Kahawita and Sirimanna too found that medical officers had missed the diagnosis of leprosy patients on a considerable number of occasions. A similar deficiency of knowledge was observed in M.P. Wijerathna and T. Ostbye’s “Knowledge, attitudes, and practices relating to leprosy among public health care providers in Colombo”, among public healthcare workers in the Colombo Municipal Council.  

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