|Year : 2018 | Volume
| Issue : 1 | Page : 26-30
Childhood leprosy in the postelimination era: A vision achieved or a concern growing at large
Ashwini Babu, M Ramesh Bhat, Jyothi Jayaraman
Department of Dermatology Venereology and Leprosy, Father Muller Medical College, Mangalore, Karnataka, India
|Date of Web Publication||28-Dec-2017|
Department of Dermatology Venereology and Leprosy, Father Muller Medical College, Mangalore - 570 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The proportion of childhood leprosy has been gaining importance of late as a performance indicator of the National Leprosy Eradication Program. A sizable proportion of the newly detected cases comprises children. The prevalence rate has been used as a measure of existence of infection though leprosy has attained elimination levels in the country. Materials and Methods: A retrospective descriptive study was conducted. Case records of children newly diagnosed with leprosy aged <15 years between April 2005 and October 2015 were studied and included in the study. Findings such as patches, nerve thickness, spectrum of leprosy, grade of deformity, smear status, presence of reaction, histopathological diagnosis, and treatment history were noted. Results: The percentage of childhood leprosy among the newly diagnosed cases in our study was found to be 11.2%. A solitary skin lesion was the most frequent manifestation in 64.4% children. The second most common finding seen in these patients included the presence of thickened nerves in 46.6% children. Smear showed acid-fast bacilli in 8.8% cases. Conclusion: There is an urgent need for improving clinical acumen in diagnosing childhood leprosy. The importance of appropriate and complete treatment along with meticulous surveillance in endemic areas and looking for household contacts needs to be stressed on.
Keywords: Childhood leprosy, concern, postelimination era
|How to cite this article:|
Babu A, Bhat M R, Jayaraman J. Childhood leprosy in the postelimination era: A vision achieved or a concern growing at large. Indian J Paediatr Dermatol 2018;19:26-30
|How to cite this URL:|
Babu A, Bhat M R, Jayaraman J. Childhood leprosy in the postelimination era: A vision achieved or a concern growing at large. Indian J Paediatr Dermatol [serial online] 2018 [cited 2018 Jan 20];19:26-30. Available from: http://www.ijpd.in/text.asp?2018/19/1/26/206064
| Introduction|| |
The leprosy control program has succeeded in the reduction of the global prevalence of the disease to 0.32 per 10,000. Areas in the Southeast Asian region with a current prevalence rate of 0.63 per 10,000 and India with a prevalence rate of 0.68 per 10,000 population require special focus.
In the year 2012–2013, 13,387 (81.9%) of the newly diagnosed cases of leprosy were from India. Children <15 years comprised 10% of these cases. Among the children, 32% belonged to the multibacillary category and 68% to the paucibacillary category.
These numbers reveal that though there is a declining trend in the prevalence of leprosy over the recent postelimination years, a sizable proportion of the newly detected cases comprise children. This highlights the need to strengthen the prevention and control strategies bearing the pediatric age group in mind.
The prevalence of childhood leprosy is gaining importance of late as a performance indicator of the National Leprosy Eradication Program. The incidence and prevalence rates are required as a quantitative measure of existing infection in the postelimination period.
| Materials and Methods|| |
A retrospective descriptive study was conducted by the Department of Dermatology, Venereology and Leprosy at Father Muller Medical College, Hospital in Mangalore, India. This institute is actively involved in the control of leprosy under the National Leprosy Eradication Program.
Mangalore is located in the Western Ghats section of coastal India. The tertiary health care center where the study was conducted caters to patients from parts of South Karnataka and North Kerala.
The study was conducted with the objective of describing the demographic and clinical features of childhood leprosy in the postelimination era. Institutional Ethical Committee approval was obtained. Case records of patients diagnosed with Hansen's disease from April 2005 to October 2015 were retrieved. All newly diagnosed cases of leprosy aged <15 years were included in the study. Details of the patient such as age, sex, symptoms of anesthetic patches, number of lesions, and presence of thickened nerves were noted.
Patient was classified according to the Ridley and Jopling spectrum as: tuberculoid (TT), borderline tuberculoid (BT), mid-borderline, borderline lepromatous (BL), lepromatous (LL) leprosy, indeterminate, and pure neuritic leprosy. The presence of visible deformities, smear for acid-fast bacilli, presence of reaction, histopathological diagnosis and its correlation with clinical finding, evidence of completion of therapy, default from treatment, and relapse were noted.
The data were analyzed using statistical software SPSS (SPSS software version 16.0, SPSS Inc., Chicago, Illinois, USA). Values such as mean, standard deviation, frequency, percentage, Fischer's exact, P value and Chi-square test were determined.
| Results|| |
A total of 401 new cases of leprosy were diagnosed between April 2005 and November 2015, 45 (11.2%) cases were children aged <15 years as shown in [Table 1]. Three (6.7%) children belonged to the age group between 0 and 5 years, 10 (22.2%) children were aged between 5 and 10 years, and 32 (71.1%) children were aged between 11 and 14 years, respectively. The mean age at the time of diagnosis in the past 3 years was 10.22 years.
|Table 1: Year-wise distribution of newly detected cases of Hansen's disease with percentage of children diagnosed|
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Among the children, 23 (51.1%) were male and 22 (48.9%) were female. In the last 3 years, 3 children were newly diagnosed between April 2013 and March 2014, 5 cases between April 2014 and March 2015 and 1 case between April 2015 and November 2015 [Table 1].
All the 45 children were observed to have one or more hypoesthetic or anesthetic hypopigmented patches. A solitary skin lesion as seen in [Figure 1] was the most frequent manifestation observed in 29 (64.4%) children followed by 2–5 skin lesions in 9 (20.0%) and more than 5 skin lesions in 7 (15.6%) seen in [Figure 2].
|Figure 1: Tuberculoid leprosy with solitary annular plaque on dorsal aspect of the left hand|
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The second most common finding included the presence of thickened nerves in 21 (46.7%) children. Spanning the years between 2005 and 13, thickened nerves were felt in 17 (47.2%) out of 36 cases, in the past 3 years 4 (44.4%) out of 9 children were found to have thickened nerves which seems alarmingly consistent with the previous years and shows no decline. One child diagnosed with BT in June 2015 had left ulnar nerve thickening. On measuring cross-sectional area using an ultrasound probe, it was found to be 0.21 cm2 which was three times thicker than the contralateral corresponding nerve point.
TT was the most common clinical type in 21 (46.7%) followed by BT in 20 (44.4%). Two (4.4%) children were diagnosed with indeterminate leprosy, and 1 (2.2%) child was diagnosed with BL type. There were no new cases of LL or pure neural leprosy diagnosed during this period.
Three children presented with lepra reaction. Two children had BT with type one reaction and one child had BL with erythema nodosum leprosum lesions.
Out of the 45 children, 6 (13.3%) children had deformities. One child had foot drop, and one child had partial claw hand which accounted for 4.4% of children with visible or grade 2 deformity.
Slit skin smears were done from four sites including earlobe, forehead, chin, and buttock/thigh. The smear was stained with Ziehl–Neelsen stain to look for acid-fast bacilli and was found to be positive in 4 (8.9%) cases.
The biopsy records of 32 cases could be traced. The histopathological diagnosis was conclusive of leprosy in all the cases. Considering the clinical and histopathological diagnosis, a correlation was observed in 25 out of 32 (78.1%) cases.
All 45 cases were started on treatment with the WHO-multidrug therapy (MDT), 35 (77.8%), completed treatment, 4 (8.9%) defaulted, and 1 (2.2%) relapsed. Five (11.2%) children continue to receive the prescribed MDT regimen to date. The 6-year-old boy who relapsed has now completed the second course of MDT and has been released from treatment a year ago. A history of contact with leprosy was present, and the source was ascribed to his mother.
On comparing the data of the postelimination era with that of the preelimination period available between April 2000 and March 2005, it was seen that out of 227 new cases diagnosed 18 (7.9%) constituted children aged <15 years as shown in [Table 2].
|Table 2: Comparison of pre- and post-elimination years data for childhood leprosy|
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The majority were found to be BT in 50.0% followed by TT in 39.0% children.
One child with LL was found to be smear positive with a bacillary index of 3.5, while the remaining children were smear negative.
| Discussion|| |
The National Leprosy Eradication Program calculates the incidence of childhood leprosy by percentage of children aged <15 years among the new cases. To avoid overlap of age with older individuals, we have considered children aged <15 years for our study.
India achieved elimination status in 2005 with the prevalence below 1 in 10,000 thus the period after 2005 is considered as the postelimination era. The percentage of childhood leprosy among the newly diagnosed cases in our study is 11.2%. It is higher than the preelimination percentage of childhood leprosy. It is also slightly higher than the incidence rate for the state at 9.23% and countrywide incidence at 9.49%.
The higher value can be attributed to referred cases evaluated at our hospital and effective record maintenance. The percentage is similar to another study in Northern Kerala which lies along the same coastal belt and the percentage of childhood leprosy was found to be 12.1%.
This value remains alarmingly high and necessitates the need for stringent clinical acumen for diagnosis, emphasis on appropriate treatment, counseling for completion of therapy, meticulous surveillance in endemic areas, and searching for household contacts.
A majority of the children diagnosed with leprosy belong to the older age group category between 11 and 14 years standing at 71.1%. This is in accordance with other studies done in the same institution  as well as outside  with 75.0% and 59.3% children diagnosed with leprosy between ages 11 and 14, respectively. This can be attributed to the long incubation period of the illness, frequent misdiagnosis of the hypopigmented patch as pityriasis alba, secondary to worm infestation causing vitamin deficiencies, etc., especially in younger children where the definitive history of anesthesia and elicitation of hypoesthesia remains challenging.
Recent studies conducted at Chittagong  and Aligarh, showed that childhood leprosy comprised 7.8% and only 5.1% of total leprosy patients are registered. A majority were males at 76.3% and 58.1%, respectively, and 74% were diagnosed to have paucibacillary leprosy.
The male preponderance noted in other studies is not seen in our study. This change indicates that more women are receiving timely health interventions when compared to the past where women were poorly represented in hospital statistics. This was due to lack of financial support and hesitance to seek medical help due to cultural issues, but this trend could also indicate a higher incidence of leprosy in the girl child of late.
A thorough clinical and neurological examination is important. Nerve involvement has been associated with increased morbidity and disability. Thus, prevention of worsening of nerve involvement by early detection is of utmost importance. We do take slight reassurance in the fact that children probably acquire the infection from contacts and are less infective than primarily infected adults.
In our study, TT and BT are the most common types detected during the post- and pre-elimination years, respectively, other studies showed BT as the most common clinical type (67.8%), which was followed by LL in 7 (11.9%).
In our study, disability is noted in 4.4% as compared to a study in Chandigarh where both grade 1 and 2 disability at the time of diagnosis was observed in 40.7% patients.
The clinico-histopathological correlation is highly dependent on the site of biopsy and is subject to interobserver variation; this makes it necessary to standardize the selection of site and to look for characteristic histopathological features to subtype the disease.
In children, nonspecific histological features are due to the incompletely developed immune system. Thus, an improvisation of technical skills, supplementation of histopathological studies with immunochemical staining using mycobacterial antibodies, using fluorescent microscopy to detect the organism and determine the type of leprosy, taking biopsies from multiple sites and repetition of the same when in doubt is warranted.
The importance of field visits to trace household contacts of these children in endemic areas is important as evidenced by a study done by Sachdeva et al. where 35.0% of children diagnosed with leprosy had a household contact.
The limitations of the study are its retrospective nature, and it was conducted at a referral center and the incidence data acquired may not be representative of the general population. To be able to extrapolate the data to the general population, a similar study needs to be conducted at multiple centers for more accurate interpretation.
The incidence of leprosy in children is found to be 11.22% in the postelimination period at our institute.
Good proportion of children is being diagnosed at both hospital and community setting. They present with deformities and nerve involvement. The late diagnosis can be attributed to the lack of awareness of the damaging effects the disease can produce. Campaigns to propagate community awareness, emphasis on contact tracing, teaching patients the importance of treatment adherence, effective rehabilitative measures, active field visits, record maintenance, and surveillance remain the need of the hour to fence out the preventable morbidity of the disease.
Financial support and sponsorship
Conflicts of interest
Awarded first prize for award paper section at Indian Society for Pediatric Dermatology conference 2016 at Hyderabad between August 26 and 28.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]