Year of leprosy control a short analytical study in a colony hospital at West Delhi

Introduction

By the year 2 YK, control of leprosy as major health problem is contemplated by Government of India under the auspices of multiple agencies. Tuberculosis, both pulmonary and extra pulmonary that was thought to be weaning, has hit back with MDR tuberculosis requiring reintroduction of an anti-tuberculosis programme vigorously than ever. Even effective extended programme on control of tuberculosis might help in control of leprosy in susceptible individuals, because of commonalty in therapeutic approach. The control programme that has started with MDT (Multi-drug regimen) about a decade ago will be ending by the end of current year. Although systemic use of MDT has possible lowered down the load still awareness in patients and professionals about leprosy, in sustaining the status on control, leave aside elimination of the disease should be carefully defined, considering the multifaceted aspect of leprosy.

Materials and Methods

The material was collected during June ′99 to October ′99 as a prospective study from the General OPD of Moti Nagar Govt. Hospital located in West Delhi, as a part of integrated primary health care of the general population of the feeder area.

The selected patients were subjected to detailed history about native place, migration to Delhi, onset and duration of lesion. They were also asked about the awareness of the condition or leprosy control programme and past history of anti-leprosy treatment, results and even about defaults that might lead to complications including undesirable deformities. Family members of these cases were examined for any skin and neural le-sions carefully. A thorough clinical examination of whole body surface, peripheral nerves and disabili-ties were done as per NLEP schedule. Slit smear and biopsies were taken from the skin lesions for clinical and histopathological grading for correlation or R.J scale.

The cases were put to MDT regime (modi-fied) keeping in view the low relapse rate in fu-ture for paucibacillary cases where 50 mg. of clofazimine were added to the drugs in programme. In Multibacillary cases a 2 weeks course of Rifampicin 600 mg. once daily along with dapsone 100mg. and Clofazimine 50 mg. daily was added as per sched-ule of NLEP before instituting the WHO regimen as guide. Reaction in leprosy on date and during the course of treatment were treated with choroquine/oral steroids as recommended in manual as and when found necessary. Local application of chaulmoogra oil on hypopigmented skin lesions were advised during the course of recovery.

Results

Thirty cases of different forms of clinical leprosy were detected and worked out from vari-ous facts in this study. Out of these thirty cases, 27 were males, 2 females and 1, 5 year-old male child.

Majority of the cases belongs to the group between 11 to 40 years. Two cases of study group had definite history of leprosy in the family, one of which had possibly contracted the disease from his brother and the other from his mother. Both the sources were suffering from BL / LL type. Two out of 30 cases studied were found to have re-activation of leprosy (both clinically and histopathologically). Duration of lesions were variable as shown in [Table - 2]. [Table - 3] reflects state-wise distribution amongst migrants settled at Delhi.

Among the migrants i.e 17/30 cases stud-ied, 5 cases were residing in Delhi for more than 10 years and in 12 cases migration occurred between 1 to 5 years. The migration was for better earnings and employment with occasional visits to roots.

[Table - 4] shows clinical grading with age group. Maximum number of cases were of border-line tuberculoid (BT) and 5 cases accounted for pure neuritic type. One of the lepromatous leprosy (LL) case showed discrete nodules on abdomen which were histoid lesions.

Barring 5 defaulters, histology was done in all except neural leprosy cases. [Table - 5] shows the clinico-histopathological correlation. 16/20 clinically bt cases showed classical BT histology in 9 cases, while 2 cases showed TT histology and in 5 cases indeterminate histology was observed with inflammatory cells collection around periappendageal areas in upper and deep dermis with flattened out epidermis. One of lepromatous leprosy was of histoid type.

Reactional state noticed in 3 cases during treatment was further treated with prednisolone and chloroquine according to severity of reactional state. Twenty out of 30 cases studied were regularly under strict supervision and critical follow up. 1/30 was found to be irregular in attendance and 7/30 cases failed to keep the suggestions and defaulted. It is interesting to note that majority of the defaulters were amongst those who received inadequate therapy from field workers.

Discussion

World Health Assembly has resolved to eliminate leprosy by the end of this year.[2] This present prospective hospital based short study in a colony hospital reveals some facts from a practically non-endemic zone indicating success of elimination of leprosy requires careful assessment.[2]

Studies on leprosy in northern India are very limited, 3-6 due to poor enrolment of leprosy patients in clinic or general hospitals. With the changing scenario of migration of population in Delhi, it is observed that extensive and more studies are required for screening of the population amongst hospital attendance and sample survey in low socio-economic zones. Serious projection about the disease in the media is also required.

Leprosy is seen in all age group, although maximum number of cases were detected between 18-40 years of age compared to the age of onset of leprosy 5 in males and females being 31.49 and 29.43 years respectively in a Delhi based study. Detection of cases in the present study revealed earlier onset.

The duration of the conditions prior to detection were variable, although 12 out of 30 cases sought treatment as early as 6 months which is an encouraging feature. An equally disturbing fact is that 13 out 30 sought medical advice with duration more than 1 year.

Seventeen out of thirty patients attending this hospital were migrants settled for better eco-nomic future. UP, being the neighboring state for easy migration followed by Bihar, which are rather endemic zones, there by increasing the risk of in-fection to indigenous population as revealed by our findings: 13 out of 30 patients were locally based by birth.

Twenty out of thirty (66.66 %) cases de-tected belonged to Borderline tuberculoid type (B.T) in RJ scale compared to Jodhpur study,[3] which showed more than 50 % as polar lepromatous leprosy (LL). Family history of intra-family leprosy is seen in 2 out of 30 (6.6%) compared to 9.5% reported by earlier study.[3] Earlier studies from Northern India[1],[4] have given higher figures of intrafamilial leprosy probably because of larger sample. Only a single case of single lesion of paucibacillary leprosy (SLPB) was detected as a contact of a mother suffering from borderline lepromatous leprosy (B L) in this study.

Applicability of RJ scale was discussed in a study by Sehgal et al[5] and Verma et al,[6] in their correlation. Nonetheless clinical classification in RJ scale remains convenient to all for practical purposes in clinics. Clinico-histopathological correlation as shown in [Table - 5] in exact point at RJ scale remains elusive in macular type in particular.

Clinico-histopathological relapse in 2/30 (6.6%) of the case is a definite point to the ob-servers compared to the study with low relapse rate (1%),[7] requiring review for qualitative change in MDT schedule.

With resurgence of tuberculosis (extra-cu-taneous and cutaneous) requiring restructuring of chemotherapy to combat the onslaught, review of ongoing WHO chemotherapy in leprosy may also be required. In cutaneous tuberculosis, a spectrum is found very similar to leprosy,[8] both clinically and immunologically. MDT used in cutaneous tuberculosis is similar in P B and M B group. But in case of leprosy WHO recommendation′ appears to fall short of expected one, raising the possibility of recurrence.

Hence authors preferred MDT in line with Indian Leprosy Association guide lines,[10] showing very satisfactory clinical responses including relapse cases during follow up.

Three out of thirty (10%) in BB - LL group had lepra reaction within 1-3 months of onset of chemotherapy which was treated successfully with chloroquine and prednisolone effectively.

This study reveals the fact requiring some consideration about the availability of drugs through field workers which might be one of the causes of default. It is found that doctor - patient contact in the management to control leprosy is essential rather than an approach through field workers which may dampen the cause towards the goal.

Authors have used chaulmoogra oil dressing in trophic ulcers along with appropriate antibiotics showing excellent results in healing. Local innunction in skin lesion shows improvements in colour and sensory changes appreciably to near normal.