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Clinical Review


complex-mediated. Reactions are an additional and major cause of nerve function impairment and can oc- cur before, during, or many years after the completion of MDT. Even patients who have been diagnosed and treated for leprosy at an early stage of their disease and have not developed detectable nerve impairment are at risk of reactions. Reactions are a significant complica- tion of multibacillary leprosy affecting up to 30% of this group of patients. The management of reactions can be very difficult and often requires protracted courses of corticosteroids, particularly at high doses for type 2 reactions. Corticosteroids are essential in the treatment of reactions but inevitably lead to adverse effects with long-term therapy. In addition, they are not always ef- fective for all reactions, particularly ENL. Thalidomide is an effective alternative to corticosteroids6


but its well-


known teratogenicity has meant that regrettably many leprosy programmes discourage its use. It is important to highlight that there is no evidence to support the efficacy of NSAIDs (non-steroidal anti-inflammatory drugs) which have been erroneously advocated in some health documents as a substitute for corticosteroids: the inappropriate use of NSAIDs in managing reactions risks permanent nerve damage.7


The ideal scenario in


leprosy management is that all patients receive long- term follow-up and regular neurological assessment for any deterioration in sensory or motor function which can be indicative of a silent neuropathy. The success of MDT encouraged the World Health Assembly to strive to eliminate leprosy by the year 2000. The WHO’s definition of leprosy elimination as a public health problem was achieving a prevalence of less than 1 case per 10000 population.8


However, the


use of disease prevalence as an indicator of progress in global leprosy control was contentious as it was based on a case definition of leprosy which included only patients newly diagnosed and registered for treatment during that year. It excluded patients who had com- pleted MDT but who may have sustained nerve damage predisposing them to future complications and who were also still at risk of reactions.9


The use of this case


definition together with the fact that patients received shorter MDT treatment regimens meant that the statis- tics revealed a significant fall in the number of regis- tered leprosy cases from 5million in 1985 to 0.7 million in 2001. In reality, although improvements in leprosy programmes had been made during this period, the actual incidence of leprosy in highly endemic countries had not fallen during this time. Instead, the incidence of new cases had actually increased in the top six endemic countries which accounted for 88% of new cases (India, Nepal, Burma, Mozambique, Madagascar, and Brazil).10 A concern for those involved in leprosy care has been


References 1. Leprosy update. Wkly Epidemiol Rec 2011: 86: 389–400. http:// www.who.int/wer.


2. WHO Expert Committee on Leprosy. Seventh report. World Health Organization: Tech Rep Ser 1998; 874: 20.


3. Ridley DS, Jopling WH. Classification of leprosy according to immu- nity. Int J Lepr 1966; 34: 255–73.


4. Girdhar BK, Girdhar A, Kumar A. Relapses in multibacillary leprosy patients: effect of length of therapy. Lep Rev 2000; 71: 144–53.


5. Brandsma JW. Prevention of disability in leprosy: the different levels. Indian J Lepr 2011: 83: 1–8.


6. Moreira AL, Kaplan G, Villahermosa LG, et al. Comparison of pen- toxifylline, thalidomide and prednisolone in treatment of ENL. Int J Lep 1998; 66: 61–5.


7. Naafs B. Treatment of leprosy: science or politics. Trop Med Int Health 2006; 11: 268–78.


8. World Health Assembly. Elimination of leprosy: resolution of the 44th World Health Assembly. Geneva: World Health Organization, 1991. (Resolution No WHA 44.9)..


9. Fine PE, Warndorff DK. Leprosy by the year 2000 – what is being eliminated? Lepr Rev 1997; 68: 201–2.


10. Leprosy – global situation. Wkly Epidemiol Rec 2000; 75: 226–31. 11. Enhanced global strategy for further reducing the disease burden due to leprosy (plan period: 2011-2015). New Delhi, World Health Organization, Regional Office for South-East Asia, 2009 (SEA- GLP-2009.3).


that statistics suggesting significant improvements in disease prevalence risk have undermined leprosy con- trol programmes, particularly with regard to disability prevention. Furthermore, after MDT for leprosy ceased to be closely supervised, important aspects of leprosy management, such as reinforcement of skin care educa- tion and early pick up of nerve damage, were no longer possible. The apparent decrease in leprosy prevalence as well as growing awareness of the limitations of these earlier approaches, which focussed on decreasing the number of active infections with little emphasis on disability prevention, led to a recent change in strategy: WHO’s goal is now aimed at decreasing disease burden by reducing new cases of leprosy with grade 2 disability (defined as moderate disability where therapeutic ac- tion is needed to prevent severe disability) per 100000 population by at least 35% in 2011–2015.11


By focusing


efforts on reducing grade 2 disability it is hoped that delayed detection and treatment of leprosy, as well as risk of spread of infection, will be reduced. In summary, the cornerstones of effective manage- ment of leprosy are early diagnosis and treatment of the infection, and early recognition and management of nerve damage combined with effective health care edu- cation. Leprosy awareness must not diminish because this risks an increase in cases and increased levels of disability. The annual statistics of leprosy prevalence are encouraging but leprosy is far from being eradicated from many parts of Africa or elsewhere. Mahreen Ameen, Royal Free London NHS Fundation Trust, UK and former honorary consultant at ALERT Hospital, Addis Ababa, Ethiopia


www.africa-health.com 54 Africa Health


CPD Challenge See page 61 to test yourself on this article July 2012


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