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Leprosy (Hansen's Disease)

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Leprosy (Hansen’s Disease) 1. Case Definition 1.1 Laboratory Confirmed Case: Clinical 2. Reporting Requirements evidence of illness* with laboratory confirmation in an appropriate clinical Laboratory: specimen (e.g., biopsy of tissue affected, All positive laboratory results for M. usually skin nodes, nasal scrapings): leprae are reportable to the Public Positive acid-fast stain with typical Health Surveillance Unit by secure fax: morphology for Mycobacterium leprae (204-948-3044). OR Health Care Professional: Histopathological report from skin or Probable (clinical) cases of leprosy are nerve biopsy compatible with leprosy reportable to the Public Health (1) Surveillance Unit by secure fax: (204- 948-3044) within 5 business days of OR being identified. The Clinical M. leprae-positive PCR in any Notification of Reportable Diseases specimen. and Conditions form http://www.gov.mb.ca/health/publichea 1.2 Probable Case: Clinical illness* in a lth/cdc/protocol/mhsu_0013.pdf should person who is epidemiologically linked to a be used. confirmed case (1). *Tuberculoid or paucibacillary disease: one of a Regional Public Health or First Nations few well demarcated, hypopigmented and anesthetic Inuit Health Branch (FNIHB): skin lesions, frequently with active, spreading edges Once the case has been referred to and a clearing centre; peripheral nerve swelling or Regional Public Health or FNIHB, the thickening may also occur. Communicable Disease Control Lepromatous or multibacillary disease: Investigation Form erythematous papules and nodules or an infiltration http://www.gov.mb.ca/health/publichea of the face, hands and feet with lesions in a bilateral lth/cdc/protocol/mhsu_0002.pdf should and symmetrical distribution that progresses to be completed and returned to the thickening of the skin and loss of normal hair Public Health Surveillance Unit by distribution, particularly on the face (madarosis). secure fax (204-948-3044). Borderline (dimorphous): skin lesions characteristic of both the tuberculoid and lepromatous forms. 3. Clinical Presentation/Natural Indeterminate: early lesions, usually History hypopigmented macules, without developed tuberculoid or lepromatous features (1). Leprosy (Hansen’s disease) is a disease that mainly affects the skin and peripheral nerves, resulting in neuropathy and associated long- term consequences, including deformities and disabilities (2). Leprosy has a long latency Communicable Disease Management Protocol – Leprosy (Hansen’s Disease) December 2019 1 period that may last up to 20 years (4). The cellular immune response, and erythema clinical range from tuberculoid (paucibacillary) nodosum leprosum (ENL) (or Type 2) (PB) to lepromatous (multibacillary (MB) characterized by a systemic inflammatory leprosy is a result of a variation in the host response secondary to immune complex cellular immune response to the bacteria (3). deposition (5, 8). In a reversal reaction, the Mycobacterium leprae is capable of direct existing skin lesions become inflamed, red peripheral nerve damage, even in the and swollen; in an ENL reaction, new red absence of inflammation or a cellular immune nodules (about 1-2 cm across) appear under response (4). Signs of leprosy include pale the skin of the limbs or trunk, while the reddish skin patches with loss of sensation; original leprosy skin patches remain as they numbness or tingling of the hands or feet; were (5). ENL reactions also cause a general weakness of the hands, feet or eyelids; feeling of fever and malaise, while reversal painful or tender nerves; swellings or lumps in reactions cause few or no systemic signs and the face or earlobes; painless wounds or symptoms (5). burns on the hands or feet (5). Leprosy lesions usually do not itch or hurt; they lack 4. Etiology sensation to heat, touch, and pain (4). Eye involvement can occur, and patients should Leprosy is caused by Mycobacterium leprae, be examined by an ophthalmologist (4). The an obligate intracellular, acid-fast bacillus (4). longer the delay between the appearance of A new species of mycobacteria, known as the first symptoms of leprosy and the start of Mycobacterium lepromatosis, was isolated treatment, the more likely nerve damage will from two deceased patients who presented occur (5). Untreated leprosy can cause with diffuse lepromatous leprosy (9, 10). This progressive and permanent damage to the new bacillus is a component of the M. leprae skin, nerves, limbs and eyes (6). Differential complex. diagnosis of leprosy includes psoriasis, vitiligo, tinea versicolor, pityriasis alba, 5. Epidemiology sarcoidosis, syphilis, mycosis fungoides, 5.1 Reservoir and Source mililaria profunda, and streptocerciasis, as well as other mycobacterial infections and Humans and armadillos are the only proven infiltrative skin diseases (7). reservoirs (7). Studies have confirmed a high frequency of M. leprae infection in The long-term consequences of leprosy (e.g., asymptomatic household contacts of disfigurement of the face) are mostly due to individuals with clinically apparent leprosy nerve damage resulting directly from (11). Armadillos are a large natural reservoir infection, or as a consequence of leprosy for M. leprae in the United States such as reactions (5). A leprosy reaction is the Louisiana and Texas (12). sudden appearance of signs and symptoms 5.2 Transmission of inflammation in the skin lesions of a person with leprosy and can occur before, during or The predominant mode of transmission is after multidrug therapy (MDT) (5). There are likely through respiratory droplets or nasal two types of reaction: reversal reaction (or secretions, although transmission may also Type 1) associated with an increase in the occur through skin contact, transplacentally, Communicable Disease Management Protocol – Leprosy (Hansen’s Disease) December 2019 2 via breast milk and after zoonotic (e.g., reported in the United States each year, with armadillo) exposure (13). There is little about one-third of the cases believed to have shedding of M. leprae from involved intact been acquired locally (12). Most cases of skin (4). Patients with polymerase chain leprosy reported in the US were in native- reaction (PCR) positive nasal swabs, born citizens of Texas and Louisiana, and suggesting nasal excretion of M. leprae, among immigrants in California, Florida, New probably have the highest transmission York, and Massachusetts (4). potential (14). The most contagious Canada: Eight cases of leprosy were presentation of leprosy is lepromatous reported to the Canadian Notifiable Diseases leprosy as these patients usually carry a very Surveillance System (CNDSS) in 2015 and large number of leprosy bacilli (9). five cases reported in 2016 (18). Asymptomatic infection among blood donors may be an unapparent mode of leprosy Manitoba: As of June 4, 2019, four cases of transmission via transfusion in leprosy leprosy have been reported in Manitoba since endemic regions (15). Indirect transmission 2000. Cases were reported in 2004, 2012, is unlikely, even though the organism can 2014 and 2019. The first three cases were in survive up to seven days in dried nasal males and the last in a female. Two of these secretions (7). cases were believed to be acquired from South Asia. No additional information is 5.3 Occurrence available on the other two cases. General: The global case detection rate, 5.4 Incubation Period defined as the notification rate per 100,000 population, seems to be declining slowly (5). The incubation period ranges from one to Changes in detection rate happen slowly, many years but is usually three to five years over decades, due to the long incubation (4). The incubation period for the tuberculoid period of the disease (5). Global initiatives form appears to be shorter than for the have resulted in a reduction of prevalence lepromatous form (4). Symptoms can take up rates from > 5 million cases in the mid-1980s to 20 years to develop (4). to < 200,000 cases at the end of 2016 (16). 5.5 Host Susceptibility and Resistance More than 65% of the world’s leprosy patients reside in South and Southeast Asia; the The majority of people appear to be naturally majority of these patients reside in India (4). immune to M. leprae (12). Several genes High endemicity remains in some areas of have been identified that are associated with Angola, Brazil, Central African Republic, susceptibility to Mycobacterium leprae; Democratic Republic of Congo, India, approximately 5% of people are genetically Madagascar, Mozambique, Nepal, Republic more susceptible to infection with M. leprae of the Marshall Islands, the Federated States (4). Therefore, spouses of leprosy patients of Micronesia, and the United Republic of are not likely to develop leprosy, but Tanzania (4). Brazil is among the top-five biological parents, children and siblings who countries with the highest prevalence of are household contacts of untreated patients leprosy (17), and accounts for almost all new with leprosy are at increased risk (4). cases of leprosy detected in the Americas (16). Approximately 150 cases of leprosy are Communicable Disease Management Protocol – Leprosy (Hansen’s Disease) December 2019 3 5.6 Risk Factors ulnar nerve at the elbow, peroneal nerve at the head of the fibula or the great auricular Contacts of patients with leprosy have a nerve). Skin lesions are tested for sensation higher risk of developing leprosy than does (light touch, pinprick, and temperature the general population, especially blood- discrimination). Whenever possible, a skin related
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