Leprosy A Forgotten Illness

Ministry of Health
Department of Preventive Medicine
Field Epidemiology Training Program

Saudi Arabia

Leprosy:
A Forgotten Illness

Literature review: Communicable Disease
KSU ID Number: (9016134)

Word count: ( 1256 )
Date of submission: (29/10/2017)

TABLE OF CONTENTS 1
2
Introduction 3
Clinical Features 6
Prevalence 6
The surveillance system 6
Treatment 7
Limitation 8
Recommendation 9
Conclusion
References

List of Figures

Figure 1: Geographical distribution of new cases in 2015, by country 1
Figure 2: Hand Deformities in a person with Leprosy 2
Figure 3: KSA Regional Distribution of Leprosy 3
Figure 4: Leprosy Prevalence Rates Around the World 4
Figure 5: Leprosy distribution between Saudi and non-Saudi Nationals 5
Figure 6: Countries or Origin of non-Saudis with leprosy 5

Introduction

Leprosy is a disease caused by chronic mycobacterial infection with Myobacterium
leprae. This bacterial pathogen can severely injure the peripheral nerves and skin. The spectrum
of severity of leprosy is often determined by the immune response.[1] The presentation can range
from nerve pain to skin abscesses to mental indication.

Global leprosy cases have declined in some areas of the world, but in some countries
surrounding Saudi Arabia there are higher rates of leprosy as seen in Figure 1. Leprosy
surveillance data specifically for the Kingdom of Saudi Arabia indicate that it continues to be a
public health problem because of its long incubation period, difficulty to diagnose, its
transmissibility, and its ability to cause permanent disabilities that lead to discrimination and
stigma. [2] Furthermore, many expatriate workers and pilgrims come to Saudi Arabia from
countries disproportionately affected by leprosy [16], which represents an opportunity for the
importation of leprosy to the Kingdom. Surveillance for leprosy and continued education on the
importance of screening is essential for the eradication of leprosy in Saudi Arabia and beyond.

Figure 1: Geographical distribution of new cases in 2015, by country
Source: World Health Organization, Global leprosy update - 2015

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Clinical features

Common clinical features of leprosy include: skin lesions insensitive to heat or pressure,
loss of skin pigmentation, not being able to sweat, decreased nerve activity in limbs, congestion,
inability to close eyes completely, lesions on the cornea, loss of eyebrow hairs and/or eyelashes,
and general muscle atrophy. [3] Figure 2 shows severe hand deformities from leprosy. Because
of these diverse clinical features, it can be difficult for healthcare providers to identify leprosy.
Knowledge of the diverse clinical presentation of leprosy is essential for healthcare providers in
order to ensure accurate surveillance.

Figure 2: Hand deformities from leprosy. Accidental damage because of loss of
sensation due to nerve damage. Other results from nerve damage are infection and
bone resorption.
Source: Photo taken by Bruno Jehle.

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Prevalence

Figure 3: KSA Regional Distribution of Leprosy

Source: Assiri A, et al., Eradicating leprosy in Saudi Arabia. Travel Medicine and Infectious Disease. - 2014

The regional distribution of leprosy cases in Saudi Arabia between 2003 to 2012, is
shown in Fig. 3. In 2012, only five regions reported cases, compared to 12 in 2003. Cases were
clustered in the South-Western and Eastern regions of the country. Makkah region reported the
highest numbers of cases, over 40% of all cases from 2003 to 2012. The Eastern region reported
nearly 20% of all cases.[2] . Surveillance data found that non-Saudi nationals represent 58-75%
of Saudi leprosy cases, and the majority came from India.[2] The WHO report “Global leprosy
update, 2015: time for action, accountability and inclusion” found low rates of new diagnoses of
leprosy in the Kingdom of Saudi Arabia. In 2015, there were less than 99 new cases as shown in
Figure 4.

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Figure 4: Leprosy Prevalence Rates by Country
Source: World Health Organization - 2012

The distribution of Saudi and non-Saudi leprosy cases is shown in Fig. 5. Saudi nationals
represent 43% of all cases, with a ratio of new cases among Saudi nationals: non-Saudi nationals
of 0.74:1.[2]. There was no significant change in this ratio from 2003-2007 or from 2007-2012.
The nationalities of all non-citizen cases over time are shown in Fig. 6.[2] The majority of
patients were Indian nationals.

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.

Figure 5: Leprosy case among Saudi and non-Saudi Nationals in Saudi
Arabia (2003 - 2012)

Source: Assiri A, et al., Eradicating leprosy in Saudi Arabia. Travel Medicine and Infectious
Disease. - 2014

Figure 6: Nationalities of non-Saudis with Leprosy in Saudi Arabia.

Source: Assiri A, et al., Eradicating leprosy in Saudi Arabia. Travel Medicine and Infectious

Disease. - 2014.
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The Surveillance System

In the Kingdom of Saudi Arabia, there are 20 separate regions for health care. Each of
these regions has several healthcare facilities, both private and governmental. All health care
facilities are required to use the same leprosy surveillance system. This system collects data
about the patient and disease presentation. Nationwide reports are collected in the central public
health office in the Ministry of Health in Riyadh. There is no screening system for leprosy at the
port of entry. The surveillance system does not track citizens of Saudi Arabia who get treatment
from outside the country. [7] In the WHO’s latest publication about leprosy there is discussion
about strengthening the leprosy surveillance system through electronic case-based databases.
WHO plans to make web-based reporting available by case. This will allow the collection of all
applicable data.

Treatment

A combination of antibiotics is used for current treatment of leprosy. Dapsone and
Rifampicin are often the first option. If the leprosy is more severe, Clofazimine is added as well.
Multidrug therapy (MDT) can prevent antibiotic resistance to antibiotics which can happen
because the treatment is long term. Historically, longer courses of treatment are associated with
lower compliance and increased antibiotic resistance. [8]

Limitations

Due to the long incubation period of leprosy, it can be very difficult to diagnose it
visually. A person infected with leprosy can infect others even before they present with any signs

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and symptoms. That is why the simple method of screening, such as Lepromin skin test, should
be available at all ports of entry health inspection center for non-Saudis who are from countries
with high rates of leprosy. It may be very difficult for patients to complete treatment if they do
not live near the one main leprosy hospital in Kingdom of Saudi Arabia. The most recent
surveillance data for leprosy in Saudi Arabia was published in 2014. Abdullah M Assiri, et al,
analyzed ten years of surveillance records for leprosy may have had incomplete data because
many non-Saudi patients stay within the kingdom for only a few years. Another limitation of this
study was a lack of data on Saudis who received treatment outside of the Kingdom and data on
any infected expatriate workers who were deported. Because of the long incubations period of
leprosy, workers residing in Saudi Arabia from endemic countries such as India should have
periodic screening for leprosy.

Recommendations

For the Kingdom of Saudi Arabia to be completely free of leprosy, an effective leprosy
elimination program should be implemented by all partners, not just the MOH. This is data
driven by the results of surveillance in the study by Abdullah Assiri. Strengthening of the
surveillance system to capture all cases allow for effective monitoring and control of the disease.
Periodic medical examinations of arriving foreign nationals especially for those coming from
endemic countries, such as Indian nationals, and upon arrival at ports of entry may increase
identification of leprosy patients. It is essential to train all primary health care providers on how
to diagnose leprosy, its signs and symptoms, and the importance of MDT to treat the disease at
an early stage. Providing public awareness and education will help communities to understand
that leprosy is a treatable disease. [2]

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Conclusion

There has been a significant decrease in leprosy globally, and a significant decrease in the
Kingdom of Saudi Arabia. This is due in large part to improved surveillance of the disease and to
MDT treatment. These studies do not describe the disabilities that are the after effects of the
disease, or how these affect quality of life.

As a global health problem, leprosy continues to affect people around the world and in
the Kingdom of Saudi Arabia. The natural history of leprosy continues to be questioned. The
only way to answer these questions is to continue surveillance and research. It has been
suggested that without more research leprosy could reemerge as a significant problem
globally[10]. The development of an antibody test would be a step in the right direction because
it would increase the speed of diagnostics [11]. Understanding more about leprosy and the
evolution of its bacillus would help solve mysteries about leprosy and other diseases as well. It
could even give us a greater understanding of genetics of populations.[8] The goal of treatment,
research and surveillance is to decrease transmission of the disease, and prevent the disabilities
associated with it as well as improving the quality of the lives of those who have been affected
by leprosy.

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References:

1. Franco-Paredes, C. and A.J. Rodriguez-Morales, Unsolved matters in leprosy: a descriptive
review and call for further research. Ann Clin Microbiol Antimicrob, 2016. 15(1): p. 33.

2. Assiri, A., et al., Eradicating leprosy in Saudi Arabia: outcome of a ten-year surveillance
(2003-2012). Travel Med Infect Dis, 2014. 12(6 Pt B): p. 771-7.

3. Natale, V. Leprosy (Hansen's disease). 2012; 2012:[Available from:
http://www.forgottendiseases.org/assets/LeprosyHansen.html.

4. Pardillo, F.E., et al., Methods for the classification of leprosy for treatment purposes. Clin
Infect Dis, 2007. 44(8): p. 1096-9.

5. Veena, S., et al., Significance of histopathology in leprosy patients with 1-5 skin lesions with
relevance to therapy. J Lab Physicians, 2011. 3(1): p. 21-4.

6. Alotaibi, M.H., et al., The demographic and clinical characteristics of leprosy in Saudi
Arabia. J Infect Public Health, 2016. 9(5): p. 611-7.

7. White, C. and C. Franco-Paredes, Leprosy in the 21st century. Clin Microbiol Rev, 2015.
28(1): p. 80-94.

8. Global leprosy update, 2015: time for action, accountability and inclusion. Wkly Epidemiol
Rec, 2015. 91(35): p. 405-20.

9. Cunha, C., et al., A historical overview of leprosy epidemiology and control activities in
Amazonas, Brazil. Revista da Sociedade Brasileira de Medicina Tropical, 2015. 48: p. 55-
62.

10. problem, I.D.R.I.L.t., a.t.s. http://www.idri.org/documents/IDRILeprosyGallery, and S. .pdf.
IDRI, WA.

11. Centers for Disease Control and Prevention (CDC), Hansen’s Disease (Leprosy), Jan. 2017
https://www.cdc.gov/leprosy/treatment/

12. Anand Dara, Sunil & Babu Gadde, Rajan. (2016). Epidemiology, Prognosis, and Prevention
of Leprosy Worldwide. Current Tropical Medicine Reports. . 10.1007/s40475-016-0087-x.

13. Global leprosy update, 2014: need for early case detection. Wkly Epidemiol Rec.
2015;90(36):461–74.

14. WHO. New cases detection trends in leprosy. Geneva: World Health Organization; 2015.
http://www.who.int/lep/situation/new_cases/en/

15. World Health Organization. (2016). Global Leprosy Strategy 2016−2020: Accelerating towards a
leprosy-free world. [online] Available at: http://www.who.int/lep/resources/9789290225096/en/
[Accessed 23 Oct. 2017].

16 De Bel-Air, F. (2013). Demography, Migration and Labour Market in Saudi Arabia. The Gulf
Labour Markets and Migration. [online] European University Institute and Gulf Research
Center. Available at: http://gulfmigration.eu/media/pubs/exno/GLMM_EN_2014_01.pdf
[Accessed 25 Oct. 2017].

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