Hansen’s Disease in Londrina City
A Public Health Intervention of Leprosy in Brazil
By Eric Chow and Tania Roman
M & I 103: Parasites & Pestilence
Dr. Scott Smith; Spring 2008
INTRODUCTION
Mycobacterium leprae, the bacterium that causes leprosy was discovered in 1873
by Gerhard Henrik Armauer Hansen (“Bacteria Genomes” 2008). Also known as
Hansen’s disease, leprosy has a long history of associated stigma, which prevents people
from seeking medical treatment and often thwarts public health intervention to curb
further spread of the disease. For this reason, public health interventions should include
efforts to reduce stigma via an educational awareness program and training of local
health officials. Our project aims to establish special skin ailment units within existing
clinics in Londrina City of Brazil with the goals of diagnosing, treating and educating the
general population of the city.
BACKGROUND
Leprosy is a human disease caused by the bacillus Mycobacterium leprae (Figure
1). M. leprae is an acid-fast bacterium. As one of the slowest growing bacteria known
and its inability to grow independently, successful in vitro cultivation has never been
achieved. Although found in the same genus as the tuberculosis bacterium
(Mycobacterium tuberculosis), the two diseases cause different symptoms.
Pathology
It is hypothesized that M. leprae infects a new host by way of skin or upper
respiratory tract, but most experiments suggest the latter as the more likely possibility
(Shepard 1960). M. leprae causes a chronic disease of the peripheral nerves, skin and
mucosal membranes of the body and has an incubation period of about 3-5 years (Hart
2003). If initial symptoms are left untreated, then permanent damage may result in many
parts of the body including the eyes and outer extremities.
2
Fig. 1 The above picture shows the M. leprae bacteria in human tissue1.
The severity of the disease can exist on a spectrum of symptoms depending on the
host’s immune response, genetics and the number of bacteria that initially infect the
body. In tuberculoid or paucibacillary leprosy (PB), rashes develop on a few spots of the
body. These spots are often flat and white in color with a characteristic numbness due to
the nerve damage caused by the bacteria. The more severe form of the disease is known
as lepromatous leprosy or multibacillary leprosy (MB) (Figure 2). The infected individual
will often develop similar rashes to those with tuberculoid leprosy except that these
rashes are often raised and may be characterized as bumps. Patients with this form of
leprosy may also experience numbness and weakness to entire muscle groups. The third
form presents a combination of symptoms intermediate to both tuberculoid and
lepromatous leprosy, hence the name, borderline leprosy. Without treatment, the disease
1
“Hansen’s Disease Treatment.” National Park Service Website. 2008. Available at:
http://www.nps.gov/kala/historyculture/hansens2.htm. Accessed: 20 May 2008.
3
can either improve to a more tuberculoid form or advance to the lepromatous symptoms
(Leprosy: Merck 2003). Skin rashes may become permanent and lead to some cases of
Fig. 2 Patient with multiple white rashes that suggest an MB leprosy infection2.
face disfigurement. Further damage to the nerves may lead to severe weakening of
muscle group control of the hands and feet also known as clawed hands or foot drop.
It was once thought that it was the disease that causes limbs to fall off, however
this is not the case. As the disease progresses, symptoms become more severe, leading to
the loss of sensation of the outer extremities due to peripheral nerve damage.
Additionally, the patient cannot feel pain or temperature making cuts and burns easy to
go unnoticed. Constant damage to these areas may ultimately cause the loss of these parts
(Figure 3). Infection can also affect the eye, and if untreated, blindness may occur. Feet
sores (Figure 4) are also common symptoms as well as damage to the nasal passages.
2
Smith, D Scott. “Leprosy.” eMedicine Website. 2006. Available at:
http://www.emedicine.com/med/topic1281.htm. Accessed: 19 May 2008.
4
Diagnosis of leprosy can be easily done through the recognition of the
characteristic rashes and the accompanying numbness. Blood tests and the culturing of
bacterium are unsuccessful due to the inability of being able to culture these bacteria in
vitro. Due to the high number of bacteria in lepromatous leprosy infected individuals,
skin lesion and nasal secretion smears can be taken and viewed under the microscope. In
a laboratory setting, samples of the bacteria can be amplified using polymerase chain
reactions (PCR) and M. leprae specific primers to confirm the identity of the bacterial
infection.
Fig. 3 Leprosy patient’s hands that have been repeatedly damaged due to loss of
nerve sensation on the extremeties3.
3
Smith, D Scott. “Leprosy.” eMedicine Website. 2006. Available at:
http://www.emedicine.com/med/topic1281.htm. Accessed: 19 May 2008.
5
Treatment has been complicated due to the emergence of drug-resistant strains of
M. leprae. Until recently, dapsone was used as the main drug to cure infections of M.
leprae, however the World Health Organization (WHO) recommends the use of multidrug therapy (MDT) especially for those with the MB form of the disease. In adults with
PB leprosy, the recommended dosages are 600 mg of Rfampicin once a month and 100
mg of Dapsone daily for a duration of 6 months. For MB patients, the dosage is
recommended at 600 mg of Rifampicin once a month, 100 mg of Dapsone daily, 300 mg
of Clofazimine once a month and 50 mg of Clofazimine daily for 1 year (WHO
recommended 2008). There are reported side effects to these drugs and patients should be
aware that these symptoms typically diminish a couple of months after treatment has
stopped.
Fig. 4 Patient developing a foot sore caused by the damage from leprosy infection4.
4
Smith, D Scott. “Leprosy.” eMedicine Website. 2006. Available at:
http://www.emedicine.com/med/topic1281.htm. Accessed: 19 May 2008.
6
Epidemiology
Very little is known about the disease in its natural habitat. It is suspected that the
armadillo may be a reservoir for the disease however studies have shown that the bacteria
can also infect non-human primates and mice. Leprosy is endemic worldwide however
most of today’s cases of leprosy infections are found in the developing countries, with the
highest prevalence in India. Brazil, Myanmar and Nepal also continue to have a large
Fig. 5 Map of the prevalence of leprosy worldwide in 20075.
5
“Leprosy: Global Situation.” World Health Organization Website. 2005. Available at:
http://www.who.int/lep/situation/en/. Accessed: 18 May 2008.
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number of cases. At the beginning of 2006, the WHO recorded approximately 219,826
new cases of leprosy worldwide, which is a dramatic shift from 1993 when the number of
new cases that year was about 590,933 (“New case detection” 2005). In Brazil, there
were 43, 933 newly detected cases of leprosy in 1998 with a total of 72,953 total cases
(Cassandra, 2002). Continued public health efforts have decreased the prevalence
worldwide, however there continues to be locations that have not been reached.
Leprosy and Stigma
One of the salient characteristics of leprosy is its associated stigma and the effects
it has on early detection and adherence to treatment. Since Medieval Europe, leprosy has
been the cause of the outcast of many of its carriers, which were forced into leprosy
isolation centers. Many centuries after, in contemporary Brazil the stigma and belief
system surrounding leprosy is still very well ingrained in society. Because our proposed
health intervention aims at reducing the stigma associated with leprosy, it is important to
understand the elements of Brazilian culture that influence patient experience and shape
popular knowledge and belief about leprosy.
In Brazil, there a number of commonly held beliefs about leprosy, particularly in
the way it is transmitted. Many people believe that leprosy is highly contagious and that
it can be acquired through casual contact, from having visited a leprosarium or from a
sexual encounter. Other beliefs associate leprosy with unsanitary conditions, dogs, or
eating fish. Leprosy is also commonly known as the “falling of limps disease” and is
thought to be incurable. Moreover, the Catholic church and the Evangelical religions
strongly reinforce the idea that leprosy is a form of divine punishment. On the other
hand, Afro-Brazilian religions look at leprosy as the result of sorcery or witchcraft (White
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2002). Also, poverty increases the susceptibility to leprosy since a high level of
inequality and population growth gives rise to over-crowding, which facilitates aerosol
transmission of M. leprae. In Brazil, a significant percentage of leprosy patients live in
favelas, or slums, thus perpetuating the association of leprosy with poverty and
augmenting the stigma associate with this condition (White 2005).
Given the negative connotations that many of the folk beliefs about leprosy carry,
many people are extremely hesitant to either seek treatment once they suspect leprosy, or
to continue treatment once they start experiencing side effects that might expose their
condition to the public. This has serious medical implications because this is the main
cause of morbidity amongst leprosy patients since the loss of sensation results in
Fig. 6 During or after MDT, many leprosy patients experience a “leprosy reaction,”
which is not a side-effect but the body’s own natural immune response to MDT.
Nonetheless, this reaction often times discourages people from continuing
treatment6.
inevitable injuries to the body. Furthermore, stigma strongly influences compliance with
treatment, especially since Multi-drug therapy has many side effects, which indicate that
6
“Leprosy: Management of Complications.” World Health Organization Website. 2005.
Available at:
http://www.wpro.who.int/sites/leprosy/treatment/treatment_complication.htm. Accessed:
18 May 2008.
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the person has leprosy. The drug Clofazamine, for example, causes the skin to become
darker on in darker people, it acquires a darker reddish color, which is easily identified as
leprosy. For these reasons, health interventions that address the issue of stigma caused by
leprosy in a cultural specific context will be highly efficacious in dealing with the factors
that preclude early leprosy detection and adherence to treatment (White 2007).
Leprosy Control Precedence
Due to leprosy’s high associated mortality and morbidity, there have been a
number of collaborative efforts geared towards its control and abatement. One of the
most recent steps towards this goal was in 1991, when the World Health Assembly called
for a global effort to eliminate leprosy as a public health problem by the end of the
second millennium (Visschedijk et al, 2000). Elimination was defined as a level of
prevalence below one case per 10,000 people. One important element of this worldwide
effort was the Leprosy Elimination Campaigns (LECs), which trained health workers in
case finding, educated communities in order to increase awareness, and performed active
case finding and patient treatment.
These campaigns had considerable success in many countries, especially since the
diminishing stigma associated with leprosy resulted in a better outlook for patients (Naff,
2006). In 1997 and 1998 LECs were held in 29 Indian States and Union Territories.
More than 500,000 health workers were involved and 454, 290 new cases were detected
(Visschedijk et al, 2000). Similarly in Nepal more than 11, 000 new cases were
identified during the 1998 national campaign, while the incidence number the previous
year was around 7,500 (Ministry of Health Nepal Department of Health Services 1998).
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Furthermore, case studies have shown that community health education programs
that focused on reducing stigma and increasing acceptance of leprosy are effective in
promoting more favorable attitudes towards leprosy. For example, in Bangladesh lower
levels of prejudice towards leprosy were observed in a rural community which had
received community education as compared to the another rural community without the
health education program. In the village that did not receive health education, over 75%
of the families reported that they would not share a meal with a leprosy sufferer and 94%
cited that they would not permit their son to marry a girl who is cured of leprosy (Wong
and Subramanian, 2003).
Also, culture-specific health education programs, such as the one implemented in
Malaysia in the late 1980s, have been found to increase acceptance of leprosy messages
and improved the public’s knowledge and attitudes towards leprosy. Other countries
have been working with traditional and religious healers to provide for leprosy patients,
most likely because many patients consult them first before seeking treatment from
western health-care systems. In fact, a study in Nigeria showed 59% of the patients
consulted the folk-medicine sector as the first step in their health seeking routine.
Moreover, use of the mass media to change attitude of the masses towards leprosy
increase case detention in Sri Lanka in 1995 (Wong and Subramanian, 2003).
Other health interventions took place in India, when after the advent of the Multidrug Therapy (MDT) in 1982, the National Leprosy Eradication Program (NLEP) was
launched in 1983 with the objective of arresting the disease in all known cases of leprosy.
However, coverage with MDT remained low due to a range of organizational issues, and
a fear of the disease and associated stigma (NCMH, 2005). Nonetheless, other national
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efforts in India, such as The Bombay Leprosy Project, which was launched more than 20
years ago, have been successful in using therapeutic management for the prevention of
disabilities. The project’s administrators attributes its success to its reduction in the
social stigma in the patients’ families and the education of the community (Ganapati,
2003).
These case studies shed light on the importance of reducing stigma associated
with leprosy in order improve the effectiveness of other health interventions. Innovated
approaches, like the extensive training of community health workers, need to be
implemented to improve community awareness and participation. In this manner,
suspected leprosy cases do not fear stigma and report to a health facility at the earliest for
timely diagnosis and prompt treatment (NCMH, 2005).
Project Location
Because a reduction in stigma associated with leprosy would be extremely
beneficial in an area with high leprosy endemicity such as Londrina, located in the state
of Parana in Southern Brazil, we chose this city as our project location. Londrina is the
second largest city in the state and counts with about half a million habitants. Most
importantly, descriptive study aimed to evaluate the leprosy control program in Londrina
from 1997 to 2001 showed that these programs lacked and failed to provide information
about leprosy, and had a significant patient dropout rate (Barro, 2004). Therefore a pilot
program would be helpful in addressing the weaknesses of previous health interventions
via a cultural sensitive approach.
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PROJECT DESIGN
The project will initially begin with a special skin ailment clinic in Londrina City,
Brazil. We will gather information by creating a focus group in order to gain a better
understanding of commonly held beliefs surrounding leprosy. From this information, the
initial group will be able to fine tune the project to meet the cultural needs of the people.
Additionally, local health officials and volunteers will be trained in diagnosing and
prescribing the medication necessary to treat patients so as to ensure the future
sustainability of the program.
Clinic
In order to eliminate the stigma that might result from establishing a clinic only
treating leprosy, we will open a special skin ailment unit aimed at joining one of the
existing community health centers or hospitals in the area. The clinic will be run by the
medical personnel that have already been trained in diagnosing leprosy. Although leprosy
is not a skin disease, its early clinical signs consist of superficial rashes of the dermis.
Thus by opening a general skin clinic, patients can feel at ease when seeking medical care
without fear of going into a clinic specific for leprosy. This clinic will provide free
diagnoses and treatment for those with leprosy. MDT is provided for by the WHO at no
cost.
To better integrate the program into the local public health services and to
encourage community involvement, we will train local health officials and volunteers as
the primary caregivers for the skin unit. Training will be feasible to be achieved because
the diagnosis of leprosy does not require special tools or skills. Often times, the disease
can be recognized through the initial skin rashes and lesions and treatment can be
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prescribed thereafter. Thus training will not only involve the WHO’s PowerPoint
presentation on the diagnosis of leprosy, but also clinical training by shadowing the group
of health professional and medical providers during daily rounds.
By the end of this initial pilot program, we hope to use the information gathered
from the focus group to better cater towards the needs of the community. What we will
learn in these initial 6 months of the program will allow us to better answer misguided
questions about leprosy and further reduce stigma by reaching out to people throughout
the entire city. The information gathered from our research may also allow us to
personalize our teaching techniques allowing for a more thorough impact on the
community at large. Through the education and continued training of local volunteers,
such a campaign to eliminate leprosy can be sustained. In the future, we hope that we
will be able to expand these skin ailment units so that people will have easy and free
access to have their leprosy infections diagnosed and treated.
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Work Referenced
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