Guidelines for the Diagnosis, Management and Prevention of Leprosy February 2019 Contents Chapter 1 9 1.0 Introduction 9 References 11 Chapter 2 Epidemiology 12 2.1 Global epidemiology 12 2.2 National epidemiology 13 2.3 Western Australia epidemiology 14 References 16 Chapter 3 Global Considerations 17 References 18 Chapter 4 Case definition 19 References 21 Chapter 5 Diagnosis of Leprosy 22 5.1 Clinical diagnosis 22 5.1.1 Presentation 22 5.1.2 Skin examination 23 5.1.3 Nerve palpation 24 5.1.4 Assessment of nerve function 25 5.1.5 Pain assessment 29 5.1.6 Eye Examination 30 5.1.7 Leprosy in Children 32 5.2 Laboratory Diagnosis 33 5.2.1 Introduction 33 5.2.2 Slit skin smears 33 5.2.3 Skin biopsy 35 5.2.4 Nerve biopsy and fine needle aspiration. 36 5.2.5 Molecular testing 37 5.2.6 Susceptibility testing 37 5.2.7 Quality control 39 5.2.8 Laboratory notification of results 39 5.3 Other diagnostic tools 39 5.3.1 Nerve conduction studies 39 5.3.2 Imaging 39 5.4 Disease Classification and Assessment 40 5.4.1 Introduction 40 Page 2 of 150 5.4.2 Ridley-Jopling classification 42 5.4.3 WHO Classification 42 5.4.4 NLEP Classification 42 5.4.5 Disability Grading 43 5.4.6 Case notification 45 5.4.7 Functional assessment 45 References 47 Chapter 6 Medical Treatment of Leprosy 50 6.1 Introduction 50 6.2 Principles of drug therapy for leprosy 51 6.3 Pre-treatment investigations and documentation 51 6.4 Treatment planning 51 6.5 Treatment Regimens 52 6.5.1 Patient monitoring while receiving leprosy treatment 53 6.5.2 Treatment completion 55 6.5.3 Follow up after completion of therapy 55 6.6 Alternative regimens 58 6.7 Regimens for drug-resistant leprosy 59 6.8 Adverse drug effects 59 6.9 Special considerations 60 6.9.1 Pregnancy 60 6.9.2 Co-existent active tuberculosis 61 6.9.3 Co-existent latent tuberculosis 61 6.9.4 Co-existent Human Immunodeficiency Virus infection 61 6.9.5 Treatment interruption and default 62 6.10 Retreatment 63 6.10.1 Definitions 63 6.10.2 Differentiating relapse from reactional state 63 6.10.3 Management of retreatment cases 65 References 66 Chapter 7 Diagnosis and Management of Neuritis and Reactional States 68 7.1 Diagnosis of neuritis and reactional states 68 7.1.1 Introduction 68 7.1.2 Neuritis 69 7.1.3 Type 1 Reaction 69 7.1.4 Erythema Nodosum Leprosum 71 7.1.5 Lucio’s Phenomenon 73 Page 3 of 156 7.2 Treatment of neuritis and lepra reactions 74 7.2.1 Introduction 74 7.2.2 Type 1 Reaction and acute neuritis 74 7.2.3 Treatment of Erythema Nodosum Leprosum 80 7.2.4 Treatment of Lucio’s Phenomenon 82 References 83 Chapter 8 Prevention and management of disability 85 8.1 Introduction 85 8.2 Early detection and treatment 86 8.3 Accurate assessment of disability at the time of diagnosis and at subsequent assessment 87 8.4 Early detection and treatment of leprosy reactions and acute neuritis 87 8.5 Self-care 88 8.6 Access to a multidisciplinary team 90 8.6.1 Reconstructive surgery 91 8.7 Ongoing surveillance 91 References 92 Chapter 9 Case Management 93 9.1 Introduction 93 9.2 Components of case management 94 9.3 Case detection 94 9.4 Assessment 94 9.5 Care planning 95 9.5.1 Case management meeting 95 9.6 Care coordination 96 9.6.1 Medication management 97 9.6.2 Self-care support 99 9.6.3 Advocacy and negotiation 99 9.6.4 Psychosocial support 100 9.6.5 Clinical handover 100 9.6.6 Monitoring and review 100 9.7 Case closure 101 References 102 Chapter 10 Prevention of Leprosy 103 10.1 Introduction 103 10.2 BCG Vaccination 103 10.2.1 Western Australia BCG Policy 104 Page 4 of 156 10.3 Chemoprophylaxis 105 10.3.1 Review of evidence 105 10.3.2 WHO Recommendations 106 10.3.3 Western Australian recommendations 106 10.3.4 Process for Chemoprophylaxis 107 References 108 Chapter 11 Contact Tracing 110 11.1 Rationale 110 11.1.1 Transmission 110 11.1.2 Incubation period 110 11.2 Governance 111 11.3 Definitions 111 11.3.1 Index Case 111 11.3.2 Household (close) contacts 111 11.3.3 Community contacts 111 11.4. Extent of contact tracing 112 11.4.1 Timeframe 112 11.4.2 Who to contact trace 112 11.5 Procedure for contact tracing 112 11.5.1 Review of Index case 112 11.5.2 Stratification of Contact List 112 11.5.3 Contact screening 113 11.6 Other considerations 114 11.6.1 Maintaining confidentiality of the index case 114 11.6.2 Contacts declining screening 114 11.6.3 Media attention 114 References 115 Chapter 12 Notification of leprosy and enhanced surveillance 116 12.1 Introduction 116 12.2 Statutory medical notifications 116 12.3 Case definition for leprosy 116 12.4 Notification and surveillance process 117 12.4.1 Western Australia 117 12.4.2 National Notifiable Diseases Surveillance System (NNDSS) 118 References 119 Appendix 1 Template for skin examination 120 Page 5 of 156 Appendix 2 Guide to performing a VMT-ST: Referral centre (See Appendix 4 for guide to performing VMT-ST) 121 Appendix 3 Guide to performing a VMT-ST: Peripheral centre 123 Appendix 4 Guide to performing a VMT-ST and palpating peripheral nerves 124 Appendix 5 DN4 – Questionnaire 126 Appendix 6 Laboratory reporting for Mycobacterium leprae drug resistance testing 127 Form 1 Mycobacterium leprae drug resistance testing: Clinical report form 127 Form 2 Testing laboratory report 128 Form 3 Reporting form for treatment outcomes of resistant cases 130 Appendix 7 ISF Score Summary Sheet 131 Appendix 8 Leprosy Enhanced Surveillance Form 132 Appendix 9 WHOQOL-BREF 135 Scoring 139 Appendix 10(a) Leprosy clinical care template PB leprosy 140 Appendix 10(b) Leprosy clinical care template MB leprosy BI 1-3+ 141 Appendix 10(c) Leprosy clinical care template MB leprosy BI 4-6+ 142 Appendix 11 Drugs used to treat leprosy 143 Appendix 12 Type 1 reaction severity scale 145 Appendix 13 Enlist ENL Severity Scale 147 Appendix 14 DOT Log Sheet 149 Appendix 15 Leprosy contact screening form for consideration of chemoprophylaxis 151 Appendix 16 Guideline for leprosy contact tracing in Western Australia 152 Appendix 17 Notification form 153 Page 6 of 156 List of Abbreviations AFB Acid Fast Bacilli BB Borderline-borderline BCG Bacillus Calmette-Guerin BI Bacillary index BL Borderline-lepromatous BT Borderline-tuberculoid CDCD Communicable Disease Control Directorate CDNA Communicable Diseases Network Australia CMI Cell mediated immunity DN4 Douleur Neuropathique en 4 DNA Deoxyribonucleic Acid DOT Directly observed therapy EHF Eye hand foot score ENL Erythema nodosum leprosum FD-MDT Fixed duration multi drug therapy G2D Grade 2 Disability GLP Global Leprosy Program Hpf High power field HRUS High resolution ultrasonography ISF Impairment severity form LL Lepromatous-leprosy MDT Multi drug therapy MI morphological index MRC Medical Research Council MRL Mycobacterium Reference Laboratory NCS Nerve conduction studies NFI Nerve function injury NNDSS National Notifiable Diseases Surveillance System PCR Polymerase Chain Reaction PEP Post exposure prophylaxis POD Prevention of Disability QEII Queen Elizabeth II (Sir Charles Gairdner Hospital) ROM Rifampicin Ofloxacin Minocycline SDR Single dose rifampicin SSS Slit skin smear ST Sensory testing T1R Type 1 reaction TB Tuberculosis TT Tuberculoid VMT-ST Voluntary muscle testing-sensory testing WA Western Australia Page 7 of 156 WANIDD Western Australian Notifiable Infectious Disease Database WGS Whole Genome Sequencing WHO World Health Organization Page 8 of 156 Chapter 1 1.0 Introduction Leprosy (also known as Hansen’s disease) is chronic granulomatous disease caused by infection with Mycobacterium leprae. The disease is characterised by skin lesions and nerve damage, with involvement of the respiratory tract, eyes, and other organs occurring less commonly. The diagnosis of leprosy is based primarily on the clinical findings of peripheral nerve enlargement, characteristic skin lesions (hypoanaesthetic hypopigmented or reddish), and compatible microbiology (presence of acid-fast bacilli in skin smears or biopsies) or histopathology. The disease is classified broadly into two categories based on the number of skin lesions; paucibacillary leprosy (2-5 lesions) and multibacillary leprosy (6 or more lesions). A three-drug regimen is used for treatment, with duration determined by disease classification. Case management is an important component of treatment, ensuring optimisation of drug therapy, early detection of lepra reactions and provision of social support. Identification and surveillance of contacts plays an important role in the prevention of leprosy, facilitating early diagnosis of secondary cases and provision of chemoprophylaxis if indicated. The clinical manifestations of leprosy are determined largely by the host immune response to M.leprae, with the spectrum of disease ranging from localised cutaneous disease, to disseminated disease with widespread skin lesions and nerve involvement. While leprosy is not considered to be a highly contagious disease, the dynamics of transmission are not well understood. Susceptibility to disease is believed to be influenced by genetic determinants, with the majority of people unlikely to develop infection if exposed. The incubation period is highly variable and potentially very long, ranging from 2-30 years. The sequelae of disease including stigma, psychological suffering and deformity contribute to a significant burden which affects the patient well beyond completion of drug therapy. A long -term sustainable approach is therefore required to address the public health and individual consequences of leprosy.