Factors associated with the worsening of the disability grade during leprosy treatment in Brazil.

OBJECTIVES: To analyse factors associated with the worsening of physical disabilities during the treatment of leprosy in Brazil in cases that were newly diagnosed in 2009. METHODS: This epidemiological study performed as a retrospective cohort investigated the factors associated with the worsening of the physical disability grade during the treatment of paucibacillary and multibacillary leprosy cases. Logistic regression with a confidence interval of 95% was used to analyse the variables associated with the worsening of disability grade. RESULTS: The cases with the greatest odds for worsening physical disability grade were patients from the south (odds ratio [OR] = 2.60) and southeast regions (OR = 1.74); with multibacillary disease (OR = 3.48); who were illiterate (OR = 2.26); and with reactive episodes (OR = 2.42). CONCLUSIONS: The factors associated with higher odds of worsening physical disability during treatment demonstrate failure to apply appropriate remedial measures to prevent disabilities, and greater attention should be given to patients with the most severe disease.

Prevalence of Disability and Associated Factors among Registered Leprosy Patients in All Africa Tb and Leprosy Rehabilitation and Training Centre (ALERT), Addis Ababa, Ethiopia.

BACKGROUND: Delay in leprosy diagnosis and treatment causes disabilities due to nerve damage, immunological reactions and bacillary infiltration. Leprosy disability leads not only to physical dysfunction and activity limitation but also disrupts social interaction of affected individuals by creating stigma and discrimination. This study was aimed at assessing leprosy disability status in patients registered at All African TB and Leprosy Rehabilitation and Training Centre. METHODS: Medical records of leprosy patients registered from September 11, 2010 to September 10, 2013 G.C were reviewed. Prevalence of disability calculated, bivariate and multiple logistic regressions were used to determine crude and adjusted odds ratios with 95% confidence interval. RESULTS: The overall prevalence of disability was found to be 65.9% from all categories of patients (40.2% Grade I and 25.7% Grade II). The Prevalence among the new category was 62.8% (39.1% Grade 1 and 23.7% Grade 2). Those ageed above 30 years, with duration of symptoms 6-12 months and above 24 months, with sensory loss, nerve damage and reversal reaction were more likely to develop disability. CONCLUSION: In this study the prevalence of disability, both Grade I and II, is very high. Disability was associated with age, duration of symptom, sensory loss, signs of nerve damage and reversal reaction. These risk factors indicate the existence of delay in diagnosis and treatment of leprosy cases. Therefore, the national leprosy control program should investigate leprosy case detection and diagnosis system in the country and work on improving early case detection and prevention of disability.

Rabies, tetanus, leprosy, and malaria.

The developing world is still endemic to rabies, tetanus, leprosy, and malaria. Globally more than 55000 people die of rabies each year, about 95% in Asia and Africa. Annually, more than 10 million people, mostly in Asia, receive postexposure vaccination against the disease. World Health Organization estimated tetanus-related deaths at 163000 in 2004 worldwide. Globally, the annual detection of new cases of leprosy continues to decline and the global case detection declined by 3.54% during 2008 compared to 2007. Malaria is endemic in most countries, except the US, Canada, Europe, and Russia. Malaria accounts for 1.5-2.7 million deaths annually. Much of the disease burden related to these four infections is preventable.

Progression of leprosy disability after discharge: is multidrug therapy enough?

OBJECTIVE: To evaluate the risk factors related to worsening of physical disabilities after treatment discharge among patients with leprosy administered 12 consecutive monthly doses of multidrug therapy (MDT/WHO). METHODS: Cohort study was carried out at the Leprosy Laboratory in Rio de Janeiro, Brazil. We evaluated patients with multibacillary leprosy treated (MDT/WHO) between 1997 and 2007. The Cox proportional hazards model was used to estimate the relationship between the onset of physical disabilities after release from treatment and epidemiological and clinical characteristics. RESULTS: The total observation time period for the 368 patients was 1 570 person-years (PY), averaging 4.3 years per patient. The overall incidence rate of worsening of disability was 6.5/100 PY. Among those who began treatment with no disability, the incidence rate of physical disability was 4.5/100 PY. Among those who started treatment with Grade 1 or 2 disabilities, the incidence rate of deterioration was 10.5/100 PY. The survival analysis evidenced that when disability grade was 1, the risk was 1.61 (95% CI: 1.02-2.56), when disability was 2, the risk was 2.37 (95% CI 1.35-4.16), and when the number of skin lesions was 15 or more, an HR = 1.97 (95% CI: 1.07-3.63). Patients with neuritis showed a 65% increased risk of worsening of disability (HR = 1.65 [95% CI: 1.08-2.52]). CONCLUSION: Impairment at diagnosis was the main risk factor for neurological worsening after treatment/MDT. Early diagnosis and prompt treatment of reactional episodes remain the main means of preventing physical disabilities.

Neurological disability in leprosy: incidence and gender association in Sergipe, Brazil.

The environmental impact assessment process is over 40 years old and has dramatically expanded. Topics, such as social, health and human rights impact are now included. The main body of an impact analysis is generally hundreds of pages long and supported by countless technical appendices. For large, oil/gas, mining and water resources projects both the volume and technical sophistication of the reports has far exceeded the processing ability of host communities. Instead of informing and empowering, the reports are abstruse and overwhelming. Reinvention is required. The development of a visual integrated impact assessment strategy that utilizes remote sensing and spatial analyses is described.

A comparison of the change in clinical severity scale score and a retrospective physician assessment of neurological outcome in individuals with leprosy associated nerve function impairment after treatment with corticosteroids.

OBJECTIVES: To determine whether the measured change in score of a validated clinical severity scale reflected physician assessed improvement in individuals who had received corticosteroid therapy for leprosy associated nerve damage. DESIGN: Patients with nerve function impairment who participated in a randomised controlled trial of corticosteroids were classified into two groups using a retrospectively determined physician assessment of improvement. One group consisted of patients who had recovered or improved the other of patients who were unchanged or had deteriorated. The change in the clinical severity scale scores of these two groups was compared. RESULTS: The change in the clinical severity scale scores of the 34 eligible individuals in the two groups were significantly different (P = 0.003). Individuals in the group who recovered or improved had a greater change in severity score than those whose nerve function was unchanged or deteriorated. CONCLUSION: The scale for measuring the severity of leprosy Type 1 reactions (T1Rs) and/or nerve function impairment reflects the clinical improvement of individuals with leprosy associated nerve damage.

[Neurological evaluation of the leper king Baldwin IV of Jerusalem]. / Manifestaciones neurológicas de la lepra del rey Balduino IV de Jerusalén.

INTRODUCTION: In the medieval period, physicians became more aware of leprosy symptoms and differentiated it from other similar diseases. Baldwin, the leper king of Jerusalem (1161-1185), probably contributed to an increasing interest and tolerance to this disease in medieval Christian states. We review historical descriptions of the neurological manifestations he developed. DEVELOPMENT: William of Tyre gives us a description of first symptoms experienced by the prince when aged nine. He notices that half of his right arm and hand were partially numb. No skin or nervous lesions are described. By his early twenties, muscle weakness makes him unable to walk. He gets blinded, probably due to keratopathy related to facial nerves involvement. Repeated attacks of fever lead to progressive worsening of his disease. He finally dies in Jerusalem, aged twenty-five, probably due to a septicaemia from infected sores. The earliest sign of Baldwin's disease is anaesthesia. Though skin lesions are not described, it is likely that at this point he had a tuberculoid form of leprosy. As his disease finally takes a lepromatous form, we suspect that it began as a borderline, immunologically unstable form. CONCLUSION: Leper king Baldwin biography gives us interesting descriptions of neurological clinical features of leprosy. Besides, it helps us to discover twelfth century medicine knowledge about this disease.

Evaluation of simplified tests for the diagnosis of nerve function impairment in leprosy: the Sensory Motor Screening (SMS) study.

OBJECTIVE: Rapid and simple tests for diagnosing nerve function impairment (NFI) in leprosy are required in integrated settings. We examined whether simplified tests performed by newly trained general health workers (GHWs) have comparable diagnostic accuracy to the reference test conducted by experienced physiotherapists. DESIGN: This multi-centre study from India and Bangladesh evaluated three simplified tests named: ILEP Learning Guide Two (M2), Indian dance (M3), and a questionnaire (M4) in 408 people affected by leprosy. Sensitivity (Se) and specificity (Sp) of the three tests were calculated using the full assessment (M1) as reference. Se and Sp were calculated at both whole body and individual nerve levels: whether any NFI and if single NFI (voluntary muscle testing of lid gap, eye closure, little finger out, thumb up and foot up, sensory testing of hands and of feet) was present. RESULTS: M2 had 83% Se and 69% Sp, M3 had 76% Se and 84% Sp and M4 had 85% Se and 46% Sp in diagnosing any NFI. At the level of single NFI, M2 was most or similarly accurate in diagnosing single NFIs with highest prevalence (ST feet, ST hands, little finger out, thumb up), compared to M3 and M4. CONCLUSIONS: ILEP Learning Guide Two (M2) and Indian dance (M3) were found to be the most accurate simplified tests for diagnosing the presence of NFI compared to the reference. M2 was the most useful test, because of greatest accuracy for most of the common types of NFI and inclusion of sensory testing of the hands. M2 is considered to be a useful tool in the hands of GHWs with time constraints in integrated settings.

Highly active antiretroviral therapy access and neurological complications of human immunodeficiency virus infection: impact versus resources in Brazil.

Currently, there are almost 600,000 human immunodeficiency virus (HIV)-infected individuals in Brazil. From 1984 to 2004, 362,364 acquired immunodeficiency virus (AIDS) cases were officially reported and 155,000 patients are under highly active antiretroviral therapy (HAART) treatment. Like in developed countries, universal access to treatment in Brazil has definitively changed both mortality and morbidity of AIDS. Today, the median survival time is 58 months, with a 2-year survival of 63%, versus 18 months before HAART. As expected, the incidence of nervous system opportunistic infectious diseases and tumors has also decreased in Brazil. However, few Brazilian reports about neurological manifestations of HIV infection are available, particularly after the beginning of more effective antiretroviral therapy. Autopsy series report that toxoplasmosis is the most prevalent neurological disease, followed by cryptococcosis and HIV encephalitis. A much lower incidence of progressive multifocal leukoencephalopathy has been described in Brazil than in reports from developed countries. A possibility for this discrepancy could be differences in terms of JC virus (JCV) isolates or even the interactions between JCV and local HIV strains. Some particularities about the involvement of the nervous system in Brazilian patients are worthy of note, such as the occurrence of central nervous system involvement in chronic Chagas' disease in patients with AIDS, and the concomitance of leprosy and HIV infection. National surveillance of neurological manifestations of HIV infection is needed to ascertain the real impact of HAART on nervous system diseases associated with AIDS in Brazil.

Nerve thickening in leprosy patients and risk of paralytic deformities: a field based study in Agra, India.

This paper examines the extent of nerve thickening among leprosy patients detected in the field in Agra district. All the clinically diagnosed leprosy patients were examined in detailed for thickening of local cutaneous nerves and peripheral nerve trunks. In each case all the major nerve trunks in both upper and lower extremities, forehead and neck were examined for thickening. Nerve thickening was found in 94% of multibacillary (MB) patients and among 52% paucibacillary (PB) patients. Nerve thickening was found to be more in males, in prevalent cases than in new (untreated) cases and increased significantly with age and delay in diagnosis (P<0.001). Visible deformities of grade > or =2 were found in 10% (58/573) of the leprosy patients; paralytic deformity accounted for 78% (45/58). Claw hand alone or in combination was seen in 82% (37/45) of patients with paralytic deformities. Risk (odd ratio) for deformities was observed to be high (15-18 times) with increasing number of nerves among patients with neuritic leprosy but correlated with delay in diagnosis of over 5 years. Likewise, deformities were more often seen in those with skin lesions, provided they had > or =3 thickened nerves. Findings suggest that early detection and treatment is useful in preventing deformities.

[Current management of hand leprosy]. / La prise en charge actuelle des mains lépreuses.

Leprosy, a chronic infectious disease caused by mycobacterium leprae affects an estimated 700,000 persons each year. Clinically, leprosy can be categorized as paucibacillary or multibacillary disease. Leprosy is important largely because of the deformities, disabilities and handicap it causes in a proportion of those affected by the disease. There are surgical procedures and techniques to correct or limit the deterioration of these conditions. In the past these surgical procedures were only performed in special institutions for treating leprosy and their complications. However, with the widespread use of multidrug therapy (PCT) and the consequent reduction in the prevalence of leprosy, there is progressive integration of the care of people affected by leprosy into the general health services. Surgery, as in intervention in the management of leprosy and its complications is used in patients who are already under anti-leprosy treatment, or after the have completed it satisfactorily. Therefore, preventive surgery like nerve decompression and corrective surgery should not be practiced in places where there is no leprosy program. This paper describes the nerve decompression for preventing paralytic deformities. Procedures for correction of claw deformity of finger and thumb resulting from ulnar or combined ulnar and median nerve paralysis, so commonly seen in leprosy-affected persons are given separately. In order to carry out these procedures, many involving tendon transfers with or without tendon grafting, the surgeon has to be well versed in the structural and functional anatomy of the hand and should training in hand surgery. Furthermore, supportive physiotherapy and if possible, occupational therapy services for pre and post-operative management of the hand should be available. If the corrective procedures are carried out in the absence of any of these requirements, the venture is bound to result in failure, worsen the hand disability as well as make any subsequent correction very much more difficult.

La cara en lepra

El presente trabajo intenta reflejar las diferentes manifestaciones clínicas dermatológicas, muconasales, neurológicas y oftalmológicas junto a las que ocurren durante las leproreacciones en la enfermedad de Hansen tanto multibacilares como paucibacilares. Se hace referencia al diagnóstico, clasificación y tratamiento local y general de la misma (AU)

Nerve function impairment in leprosy: design, methodology, and intake status of a prospective cohort study of 2664 new leprosy cases in Bangladesh (The Bangladesh Acute Nerve Damage Study).

The Bangladesh Acute Nerve Damage Study (BANDS) is a prospective cohort study designed to investigate epidemiological, diagnostic, therapeutic and operational aspects of acute nerve function impairment in leprosy. The study is based at a single centre in Bangladesh, in an area with a high prevalence of leprosy. The centre, Danish Bangladesh Leprosy Mission, has a well-established vertical leprosy control programme. In this paper, the study design and methodology are described, together with definitions of nerve function impairment (NFI) used in this and subsequent papers. The study recruited 2664 new leprosy cases in a 12-month period. The male:female ratio is 1.25:1, and 17.61% of the cohort are under 15 years of age. In all, 83.33% of the cohort are paucibacillary (PB), and 16.67% multibacillary (MB). However, the MB rate amongst males is 19.72%, and amongst females is 12.85%, despite an equal period of delay to diagnosis. 55% of patients presented for treatment within 12 months of developing symptoms 6.12% of the total number of cases were smear positive, and 36.71% of the MB cases were smear positive. 9.61% of the total number of cases were graded as having World Health Organisation (WHO) disability grade 1, and 5.97% had grade 2. Amongst MB cases, 27.48% had WHO grade 1 disability present, and 18.24% had grade 2 present, compared with 6.04% and 3.51%, respectively, amongst PB cases. A total of 11.90% of the cohort had sensory NFI of any kind, and 7.39% had motor NFI. Ninety patients presented with NFI needing treatment (3.38%), and of these, 61 (67.78%) had silent NFI. MB patients had a prevalence of reaction/NFI needing treatment nearly 7 times higher than PB cases (15.32% amongst MB; 2.30% amongst PB), and males nearly double that of females (5.67% amongst males, 2.96% amongst females). The most commonly affected nerve by function impairment was the posterior tibial (sensory) with 6.46% of nerves affected (9.38% of patients), followed by the ulnar nerve with 3.23% of nerves impaired (5.56% of patients). Future research and publications, building on this foundation, will focus on the following areas: the incidence of NFI and reactive events, the risk factors for developing NFI, and the response to treatment of patients developing acute NFI.

Incidence of contralateral versus ipsilateral neurological signs associated with lateralised Hansen type I disc extrusion.

Asymmetrical neurological signs were noted in 50 dogs presenting with Hansen type I thoracolumbar disc extrusion. Thoracolumbar myelograms and surgical decompression were performed in all cases. Dogs were divided into two groups (acute and chronic) based on the duration of clinical signs prior to presentation to the University of Georgia. Lateralising extradural cord compressive lesions were noted on all myelograms. In the acute group, 35 per cent of the dogs had asymmetrical neurological signs contralateral to the myelographic and surgical lesion, while in the chronic group only 11 per cent had neurological signs contralateral to the lesion. There was found to be no significant difference in frequency of contralateral asymmetrical clinical signs between the two groups (Fischer's exact test; P = 0.095). The high frequency of contralateral signs documents the importance of thoracolumbar myelography for accurate localisation of the disc material before decompressive surgery.

Nerve function impairment in leprosy at diagnosis and at completion of MDT: a retrospective cohort study of 786 patients in Bangladesh.

This retrospective cohort study includes all new leprosy patients registered for multidrug therapy (MDT) in 1990 at the Danish-Bangladesh Leprosy Mission project in Bangladesh. The main objective was to determine the extent of nerve-function impairment (NFI) at diagnosis and at completion of MDT, and to identify opportunities for intervention and their relative impact on the prevention of disabilities (POD). A total of 786 patients were included; 486 males and 300 females. There were 315 PB, and 471 MB patients. In terms of the WHO leprosy disability grading system, at the time of diagnosis 31/315 (9.8%) had grade 1 or grade 2 disability in the PB group, and 177/471 (37.6%) in the MB group. The incidence rate of NFI during MDT was 3.5 per 100 person years at risk (PYR) in the PB group, and 7.5 per 100 PYR in the MB group. In the MB group 37 (7.9%) previously normal patients sustained NFI during MDT, whilst 19 (4.0%) with NFI at diagnosis showed complete recovery at completion of MDT. The most commonly involved nerves were the ulnar (motor function) and the posterior tibial nerves (sensibility). Reversal reactions were observed in 0.6% of the PB patients during MDT, giving an incidence rate of 1 per 100 PYR. The percentage of MB patients diagnosed with reversal during MDT was 14.2%, giving an incidence rate of 6 per 100 PYR. The percentage of MB patients diagnosed with ENL during MDT was 2.1%, with an incidence rate of 1 per 100 PYR. It was concluded that early detection of new cases of leprosy would prevent disabilities in more than 30% of all patients, thus having the highest impact in the quest for the prevention of disabilities. POD activities during and after MDT will prevent disabilities in approximately 10% of all cases. This study also indicates that treatment with prednisolone is effective and should be available at field level for all patients with recent NFI.