Abstract
Background:
Pediatric leprosy, though relatively less common compared to adult cases, presents challenges in diagnosis, treatment, and management. Despite global efforts to eradicate leprosy, it remains endemic in certain regions, particularly low-resource settings.
Objectives:
To analyse differences in clinical presentation of pediatric leprosy as compared to adult leprosy from leprosy clinic records of a tertiary care hospital and outline the clinical implications.
Methods:
A retrospective analysis of the records of all the registered paediatric (aged ≤ 18 years) and adult cases of leprosy from January 2010 to December 2021 (12-year period) who presented to the leprosy clinic of Guru Teg Bahadur Hospital in Delhi was carried out. History, examination, and investigation parameters were noted from standardised case record forms. The variables were compared between cases of childhood and adult leprosy.
Results:
Out of total 1006 recorded cases of leprosy, 16.8% were children and 83.2% were adults. Maximum cases (65.7%) were of borderline tuberculoid (BT) leprosy in children compared to 41.7% BT cases in adults. Type 1 and type 2 leprosy reactions were seen in 11.2% and 7.1% paediatric cases, respectively, compared to 9.8% and 12.3% cases in adults, respectively. Paralytic deformity was seen in 32.5% child cases and 35% adult cases. Claw hand and foot drop was seen in 17.2% and 3.6% cases of leprosy in children and 16.1% and 6.5% cases in adults. A total of 11.8% children developed facial palsy. Slit skin smear was positive in 15.4% paediatric and 30.1% adult cases. Treatment was completed in 65.1% child cases and 27.8% children defaulted. In adult cases, treatment was completed in 61.8% cases and 28.9% cases defaulted.
Conclusion:
Paediatric leprosy in our study had a high number of cases of type 1 lepra reaction, paralytic deformities, disabilities, pure neuritic leprosy, and default rate. Our study highlights the need of early detection, timely intervention, and increasing community awareness to ensure early and adequate management of paediatric leprosy.
KEY WORDS: Childhood leprosy, disability, leprosy reaction, retrospective study
Introduction
Leprosy is a chronic bacterial infectious disease caused by Mycobacterium leprae. It is one of the oldest diseases known to humanity and still continues to be a major public health problem in many developing countries. During the year 2022, 1,74,087 new cases were reported globally, representing an increase of 23.8% compared to that reported in 2021 (1,40,594). The South-East Asian region contributed to 71.4% of total cases with India contributing to 1,03,819 (59.6%) cases.[1] India has achieved leprosy elimination at the national level in December 2005. However, India still contributes the highest number of leprosy cases in the world. Many states and districts of India continue to have high prevalence of leprosy cases. A total of 10,302 new child cases were reported globally with 5586 cases contributed by India.[1] Children are the most vulnerable group to infection with M. leprae due to nascent immunity and exposure to infected family members. Furthermore, there is lack of typical clinical signs and symptoms in children, leading to delayed diagnosis. Number of paediatric leprosy cases is an index of prevalence of leprosy in the general population, with a high child rate indicating high transmission of infection and active circulation of the bacilli in the population, thereby serving as a marker of efficiency of the leprosy control programs.
Material and Methods
A retrospective analysis of the records of all the registered paediatric (aged ≤18 years) and adult cases of leprosy from January 2010 to December 2021 (12-year period) who presented to the leprosy clinic of Guru Teg Bahadur Hospital in Delhi was carried out. The diagnosis was based on clinical findings and histopathology reports. Parameters noted from the standardised case record forms included age, sex, duration of skin lesions, any contact with known case of leprosy, development of type 1 or type 2 reaction currently or in the past, and any sensory or motor loss. Examination points mentioned in the leprosy card were also noted, including number of skin lesions, distribution of skin lesions, number of thickened peripheral nerves, and sensory and motor examination. Signs of neuritis and nerve function impairment were also checked. Slit skin smear examination and histopathological findings were noted. Anti-leprosy treatment was given to the patients for a duration of 6 months in paucibacillary cases and 12 months in multi-bacillary cases; however, the treatment was extended to a total duration of 24 months in multi-bacillary cases with a bacteriological index of more than 4+.[2] Data were analysed using the SPSS 22.0 system. The variables were compared between cases of childhood and adult leprosy. Chi-square and Fisher exact tests were used to calculate the significance of difference between two groups, and a P value of < 0.05 was considered significant. The principles outlined in the Declaration of Helsinki were followed, and appropriate consent was obtained from the study participants recruited for this analysis.
Results
Demographic profile
Out of total 1006 recorded cases of leprosy from 2010 to 2021, 169 patients were children and 837 patients were adults. Childhood cases contributed to 16.8% of total new cases of leprosy. Table 1 and Figure 1 show year-wise distribution of adult and paediatric leprosy cases. The mean age of children with leprosy was 14.9 ± 3.93 years. There were 107 (63.3%) males and 62 (36.7%) female patients among paediatric cases as compared to 579 (69.2%) male and 258 (30.8%) female patients among adult leprosy cases. The male: female ratio for paediatric cases and adult cases was 1.7:1 and 2.2:1, respectively (P = 0.13).
Table 1.
Year-wise distribution of adult and child cases of leprosy
| Year | Total cases reported | Adult cases (n=837) | Paediatric cases (n=169) | Proportion of paediatric cases among total cases |
|---|---|---|---|---|
| 2010 | 155 | 129 | 26 | 16.8% |
| 2011 | 117 | 83 | 34 | 29.0% |
| 2012 | 102 | 87 | 15 | 14.7% |
| 2013 | 110 | 83 | 27 | 24.5% |
| 2014 | 89 | 79 | 10 | 11.2% |
| 2015 | 82 | 66 | 16 | 19.5% |
| 2016 | 73 | 65 | 8 | 10.9% |
| 2017 | 76 | 63 | 13 | 17.1% |
| 2018 | 83 | 75 | 8 | 9.6% |
| 2019 | 95 | 85 | 10 | 10.5% |
| 2020 | 12 | 11 | 1 | 8.3% |
| 2021 | 12 | 11 | 1 | 8.3% |
| 2010-2021 | 1006 | 837 | 169 | 16.8% |
Figure 1.
Trend of leprosy in adult onset and paediatric onset leprosy
Clinical spectrum
A history of family contact with leprosy was reported in significantly higher (P < 0.001) paediatric patients (12.4% cases) as compared to adults (2.4% cases). The mean duration of illness was significantly less in children (7 months) as compared to adults (12 months) with P < 0.001. A total of 23.7% adults and 36.7% children presented with a single lesion (P < 0.05) and 65.4% adults and 53.3% children presented with multiple lesions (P < 0.05). Lesions were distributed over the lower limb (24.3%), face (21.3%), upper limb (14.8%), forearm (8.3%), trunk (7.7%), hand (5.9%), buttocks (3.6%), elbow (3.0%), feet (1.8%), and legs (1.8%) in decreasing order in children. We found that children had significantly greater involvement of the acral body sites such as the forearm (8.3% vs 4.5%, P < 0.05) and lower limb (24.3% vs 10.0%, P < 0.001), in comparison to adults. Buttocks were involved in a significantly higher number of cases in adults (6%) compared to children (3.6%; P = 0.005). Table 2 depicts the distribution of leprosy lesions in children and adults. Remarkably, generalised body involvement was more evident in adults (32%) versus the paediatric cases (16%; P < 0.001). Remarkably, single-site involvement was comparable in both adults (44.5%) and children (50.9%).
Table 2.
Distribution of lesions over body in adults and children with leprosy
| Distribution | Adults (n=837) | Children (n=169) | P |
|---|---|---|---|
| Face | 138 (16.7) | 36 (21.3) | 0.150 |
| Body | 88 (10.5) | 18 (10.7) | 0.958 |
| Forearm | 38 (4.5) | 14 (8.3) | 0.045 |
| Upper limb | 100 (11.9) | 25 (14.8) | 0.306 |
| Lower limb | 84 (10.0) | 41 (24.3) | <0.001 |
| Neck | 7 (0.008) | 0 (0) | 0.372 |
| Buttock | 5 (6) | 6 (3.6) | 0.005 |
| Hand | 38 (4.5) | 10 (5.9) | 0.443 |
| Trunk | 88 (10.5) | 13 (7.7) | 0.266 |
| Elbow | 29 (3.5) | 5 (3.0) | 0.740 |
| Leg | 4 (0.5) | 3 (1.8) | 0.097 |
| Feet | 19 (2.3) | 3 (1.8) | 0.785 |
| Generalised | 268 (32.0) | 27 (16.0) | <0.001 |
As per the Ridley Jopling class, maximum cases (111, 65.7%) were of borderline tuberculoid (BT) leprosy in children; there was only 1 (0.6%) case of borderline borderline (BB), 28 (16.6%) cases of borderline lepromatous (BL), and 18 (10.6%) cases of lepromatous leprosy (LL) in children. Other clinical types of leprosy included seven cases of pure neuritic leprosy (4.1%) and two cases of indeterminate leprosy (1.2%). No case of histoid leprosy was seen in children. On the contrary, there were 349 (41.7%) cases of BT, 229 (27.4%) cases of BL, 182 (21.7%) cases of LL, and 16 (0.02%) cases of BB in adults. We documented 9 (0.01%) cases of histoid leprosy, 48 (5.7%) cases of pure neuritic leprosy, and only 1 (0.001%) case of indeterminate leprosy in adults [Table 3]. In our study, children presented with a significantly higher number of cases with BT leprosy and indeterminate leprosy (P < 0.001) and a comparable number of BL, LL, and pure neuritic and a significantly lesser number of histoid leprosy (P < 0.001).
Table 3.
Spectrum of disease in adults and children
| Spectrum of leprosy | Adult cases (n=837) | Paediatric cases (n=169) | P |
|---|---|---|---|
| Tuberculoid leprosy | 0 | 0 | <0.001 |
| Borderline Tuberculoid | 349 (41.7%) | 111 (65.7%) | |
| Borderline Borderline | 16 (1.91%) | 1 (0.005%) | |
| Borderline Lepromatous | 229 (27.4%) | 28 (16.6%) | |
| Lepromatous leprosy | 182 (21.7%) | 18 (10.7%) | |
| Histoid leprosy | 9 (1.08%) | 0 (0%) | |
| Indeterminate leprosy | 1 (0.1%) | 2 (0.01%) | |
| Pure neuritic leprosy | 48 (5.7%) | 7 (4.1%) | |
| Not classified | 3 (0.4%) | 2 (1.2%) | |
| Total cases | 837 (100%) | 169 (100%) |
Leprosy reactions
A total of 31 (18.3%) paediatric leprosy cases presented with reaction or developed it during the course of the disease; 19 (11.2%) paediatric cases presented with type 1 reaction, and 12 (7.1%) cases presented with type 2 reaction. A total of 185 (22.1%) adult leprosy cases had reaction, out of which 82 (9.8%%) cases developed type 1 reaction and 103 (12.3%) cases developed type 2 reaction. Both type 1 and type 2 reactions were less likely in children as compared to adults, but it was statistically insignificant (P = 0.447 and 0.052, respectively). Table 4 depicts the number of cases with leprosy reaction across the disease spectrum. Maximum cases of type 1 reaction were seen in BT leprosy, followed by BL, LL, and BB leprosy in decreasing order, and maximum cases of type 2 reaction were seen in LL, followed by BL in both children and adults, and the difference was significant (P < 0.001). Nerve function impairment was detected in 11.8% paediatric cases, which was higher than that of adults (9.6%); however, it was not significant (P = 0.367).
Table 4.
Number of cases with leprosy reaction in various disease spectra
| Classification | Adult cases (n=837) | Child cases (n=169) | P |
|---|---|---|---|
| BT with type 1 reaction | 48 (5.8) | 13 (7.7) | <0.001 |
| BB with type 1 reaction | 9 (1.1) | 0 (0.0) | <0.001 |
| BL with Type 1 reaction | 23 (2.7) | 6 (3.6) | <0.001 |
| LL with type 1 reaction | 2 (0.2) | 0 (0.0) | <0.001 |
| Total Type `1 | 82 (9.8%) | 19 (11.2%) | 0.447 |
| BL with type 2 reaction | 23 (2.7) | 1 (0.6) | <0.001 |
| LL with type 2 reaction | 80 (9.6) | 11 (6.5) | <0.001 |
| Total Type 2 | 103 (12.3%) | 12 (7.1%) | 0.052 |
Slit skin smear positivity and histopathology
Slit skin smear was positive in 26 (15.4%) paediatric cases. On the contrary, it was positive in 252 (30.1%) adult cases. Table 5 shows bacteriological index in adult and childhood leprosy cases. The difference in bacteriological index between adult and pediatric cases was found to be significant with a P value of < 0.05. Biopsies were done in 662 (79%) adult cases and 145 (85.8%) child cases; a total of 175 (21%) adults and 24 (14.2%) children were not willing for biopsy (P < 0.05).
Table 5.
Bacteriological index in adult and childhood leprosy cases
| Slit skin smear | Bacteriological index | Adult leprosy cases (n=837) | Paediatric leprosy cases (n=169) | P |
|---|---|---|---|---|
| Negative | 0 | 184 (22%) | 58 (34.3%) | 0.002 |
| Total smear negative cases | 184 (22%) | 58 (34.3%) | ||
| Positive | 1+ | 27 (3.2%) | 3 (1.8%) | |
| 2+ | 11 (1.3%) | 1 (0.6%) | ||
| 3+ | 21 (2.5%) | 3 (1.8%) | ||
| 4+ | 38 (4.5%) | 4 (2.4%) | ||
| 5+ | 44 (5.3%) | 4 (2.4%) | ||
| 6+ | 111 (13.3%) | 11 (6.4%) | ||
| Total smear- positive cases | 252 (30.1%) | 26 (15.4%) |
Deformity and disability
Four (2.4%) paediatric cases had glove and stocking anaesthesia, which was significantly less (P < 0.001) than adults (108 cases, 12.9%). Specific leprosy deformity was seen in 13 (1.6%) adults, and it was not seen in children (P = 0.142). Paralytic deformity was seen in 55 (32.5%) paediatric cases and 293 (35%) adult cases. Amongst paralytic deformities, claw hand and foot drop was seen in 29 (17.2%) and 6 (3.6%) cases of leprosy in children and 135 (16.1%) and 54 (6.5%) cases in adults. A total of 20 (11.8%) children presented with facial palsy or developed it later during the course of treatment. Prevalence of facial palsy in children (20 cases, 11.8%) was found to be comparable to adults (101 cases, 12.1%). Only 1 child (0.6%) presented with trophic ulcer as compared to adults (38 cases, 4.5%; P < 0.05). On comparing the number of cases with paralytic deformities (P = 0.539) including foot drop (P = 0.146), claw hand (P = 0.741), and facial palsy (P = 0.932) between adults and children, the difference was not statistically significant. Table 6 shows the number of cases with deformity and disability in adult and paediatric leprosy cases.
Table 6.
Number of cases with deformity and disability in adult and pediatric leprosy cases
| Adults (n=837) | Children (n=169) | P | |
|---|---|---|---|
| NFI | 80 (9.6) | 20 (11.8) | 0.367 |
| Glove and stocking | 108 (12.9) | 4 (2.4) | <0.001 |
| Claw hand | 135 (16.1) | 29 (17.2) | 0.741 |
| Foot drop | 54 (6.5) | 6 (3.6) | 0.146 |
| Trophic ulcer | 38 (4.5) | 1 (0.6) | 0.015 |
| Facial paralysis | 101 (12.1) | 20 (11.8) | 0.932 |
| Total cases with deformity and disability | 516 (61.6%) | 80 (47.3%) | P=0.0006 |
Treatment
Table 7 summarises the treatment outcome in adult and pediatric leprosy cases; treatment was completed in 110 (65.1%) child cases and 47 (27.8%) children defaulted, and 7.1% cases were on treatment. In adult cases, treatment was completed in 514 (61.8%) cases and 242 (28.9%) cases defaulted. However, the difference between children and adults for both treatment completion (P = 0.369) and treatment default (P = 0.773) was not significant. No relapse cases were found in this study in children; however, 5 (0.60%) adult cases relapsed (P = 0.314).
Table 7.
Treatment outcome in adult and pediatric leprosy cases
| Treatment outcome | Adults (n=837) | Children (n=169) | P |
|---|---|---|---|
| Defaulter | 242 (28.9%) | 47 (27.8%) | 0.773 |
| Completed treatment | 514 (61.8%) | 110 (65.1%) | 0.369 |
| On treatment | 81 (9.3%) | 12 (7.1%) | - |
| Total | 837 (100%) | 169 (100%) | - |
Discussion
The number of new leprosy cases in India has decreased from 1,25,785 in 2014–15 to 75,394 in 2021–22. The prevalence rate of leprosy has come down from 0.6 per 10000 population in 2014–15 to 0.45 in 2021–22. The annual new case detection rate has also come down from 9.73 per 1,00,000 population in 2014–15 to 5.52 in 2021–22.[3] However, India is still contributing to 53.6% of new global leprosy cases.[4] Delhi reported 847 new leprosy cases and 101 cases with grade 2 disability in the year 2020–21. The prevalence rate in Delhi is 0.8 per 10,000 population according to NLEP data for year 2022–23. The proportion of child cases is found to be 5.45% in 2021–22, which has dropped down from 9.04% in 2014–15. In India, 4107 new childhood leprosy cases were reported in 2021–22.
In our study, paediatric cases of leprosy contributed to 16.8% of total new cases of leprosy from 2010 to 2021; however, the cutoff age group for paediatric leprosy in our study was ≤18 years. The paediatric cases dropped down to 8.9% when the cutoff age of ≤15 years was used. The prevalence of childhood leprosy cases has been observed to range from 2.3%[5] to 34.1%[6] in various Indian studies. The upper age limit for childhood case definition is variable in various studies (<14 years to <19 years), which might be the cause for wide variation in prevalence of childhood leprosy. In our study, most of the cases of paediatric leprosy were more than 10 years of age. This could be attributed to the long incubation period of leprosy and delay in presentation and diagnosis of lesions in children.
There were 107 (63.3%) males and 62 (36.7%) female patients among paediatric cases as compared to 579 (69.2%) male and 258 (30.8%) female patients among adult leprosy cases. Boys have been found to be more commonly affected than girls in previous studies also; this may be due to neglect and less reporting of female children to the hospital.[7,8] It could also be due to increased mobility of male children and hence greater chances of contact. However, Horo et al.[9] reported a higher number of female cases compared to males, thereby highlighting the need to focus on hidden case burden in female children.
A history of contact was found significantly higher in paediatric patients (12.4% cases) as compared to adults (2.4% cases) as children are the most vulnerable group to infection with M. leprae due to nascent immunity. It was similar to the findings of other studies where familial contacts have ranged from 6.06% to 47%.[10,11,12] Familial contacts play a major role in the development of childhood leprosy, with a four times higher risk of transmission of leprosy in neighborhood contacts and nine times higher risk in intrafamilial contacts. Number of pediatric leprosy cases is an index of prevalence of leprosy in the general population. A paediatric leprosy case can be helpful in detecting the index case. Therefore, it is very important to screen the family members, especially children in leprosy cases.
Maximum cases (111 cases, 65.7%) were of BT leprosy in children. This finding was consistent with the result of other studies.[5,13,14,15,16,17] Adults in our study also have BT (349 cases, 41.7%) as the most common presentation. Our study noted that a higher number of children presented with BT leprosy as compared to adults. In most of the studies on paediatric leprosy, the most common presentation was single lesion on exposed body areas.[6,18,19] However, in our study, we also found lesions over covered areas including buttocks, trunk, and lower limbs, highlighting the importance of examination of whole body in suspected cases and while screening the contacts. Single lesion was found in 23.7% adult cases and 36.7% of paediatric cases in our study. Multiple studies[20,21] have reported single lesion as the most common presentation; however, some authors[18,22] have reported a higher rate of multiple skin lesions. We observed 38.3% of MB cases in children to be significantly lower than adults (57.8%). The majority of studies[11,23,24] have shown a higher proportion of PB cases than MB cases, which ranged from 43.4–98% (PB cases) to 2–6.6% (MB cases), and a few studies have shown a higher proportion of MB cases, emphasising the possibility of high bacillary load in children.[10,25] A total of 16.6% cases of BL and 10.6% cases of LL were seen in paediatric cases in our study compared to 27.4% cases of BL and 21.7% cases of LL in adults. The persistent presentation of cases of multibacillary leprosy, particularly in the lepromatous pole, and presence of multiple lesions in children in various studies including ours is a cause of concern and warrants attention as it could run a more severe clinical course with higher morbidity. Despite efforts to control and eliminate leprosy, these indicate ongoing challenges in disease detection and treatment access in the paediatric population. It emphasises the need of proactive measures including improved diagnostic tools, enhanced access to health care, and an enhanced surveillance system to address these challenges.
We found that children had significantly greater involvement of the acral body sites compared to adults such as the forearm and lower limb. Lesions on acral sites are particularly concerning due to their increased vulnerability to trauma, which can exacerbate tissue damage, impair wound healing, and contribute to secondary infections. Loss of protective sensations further heightens the risk of injury. Involvement of acral sites has profound functional implications, affecting the ability to perform daily activities and participate in social and recreational activities and increased stigma and discrimination.
Leprosy reactions are generally uncommon in children; however, studies have shown both low[5,6,24,26] and high[7,14,19,23,27] incidence of lepra reaction in childhood cases. All the studies have shown higher incidence of type 1 lepra reaction than type 2 reaction as BT leprosy has been found to be the most common clinical form of presentation. In our study, paediatric cases presented with type 1 reaction in almost a similar percentage of cases as that of adults. Type 2 reaction was less common in children than adults in our study, although not completely lacking, highlighting the importance of regular examination and proper counselling for awareness regarding the development of reaction. It becomes more important in children with risk factors for development of reactions such as older age of presentation, multiple skin lesions, and multibacillary forms of leprosy. Early detection and appropriate treatment of reactions can prevent the development of deformity and disability and promote better quality of life in paediatric leprosy patients.
The glove and stocking anaesthesia was found to be less common than adults in our study, which could be attributed to difficulty in detection and assessment of glove and stocking anesthesia in children requiring careful evaluation and consideration of age-appropriate assessment methods. Paralytic deformities, foot drop, and claw hand were documented in a comparable percentage of cases in adults and children. There are variable findings across studies regarding deformities in childhood leprosy showing high[14] and low rates[24,28] in various studies. These could be explained due to delay in seeking healthcare by the parents, lesser access to healthcare in rural and hard-to-reach areas, presence of signs of lepra reaction at presentation, and multi-bacillary cases. Children with deformity have a great impact in their quality of life, such as seeking education, performing daily activities, higher social stigma, and discrimination in schools. Visible stigma is a concern for children with leprosy which can manifest in forms including social exclusion, discrimination, and bullying, which have detrimental effects on the child’s mental and emotional well-being. A higher emphasis should be given to detailed sensory and motor examination at the time of diagnosis, during regular follow-up, and in children developing signs or symptoms suggestive of reaction, neuritis, or sudden onset of sensory and motor loss during anti-leprosy treatment. This should be more actively done in children with risk factors for development of deformity and disability. Also, there is a need to plan the interventions in the program to reduce the patient’s delay in presentation to healthcare services. A proper training of health workers is required to make correct diagnosis and to avoid missing any leprosy case to minimise disability among children.
Indeterminate leprosy is a common presentation of leprosy in children. It is an early and transitional stage of leprosy. It may evolve into one of the determinate leprosy or may resolve spontaneously. There were very few indeterminate cases of leprosy in children (1.2%) in our study, although they were found to be more as compared to adults (0.001%). This might be attributable to delay in presentation of our paediatric cases as children are dependent on the care givers for seeking treatment. We also noted 4.1% cases of pure neuritic leprosy in children and 5.7% cases in adults. A possibility of neuritic leprosy should also be kept in children if there is definitive nerve thickening but no skin lesions or doubtful sensory or motor loss due to difficulty in examination. We found no cases of histoid leprosy, which was consistent with other studies, and histoid leprosy is extremely rare in children.[14,24]
Diagnosis of leprosy in a child is challenging due to atypical symptoms and non-classical presentation. Conducting sensory and motor examination in a child is difficult due to limited ability to communicate and cooperate. Cases with hypopigmented patch over the face can be misdiagnosed as leprosy. Classical features of leprosy and acid-fast bacilli may not be seen on histopathology. Slit skin smear was found to be positive in 15.4% child cases in our study compared to 30.1% cases in adults. Most of the studies[10,13,26] have shown less than 10% skin smear positivity in children; however, a higher smear positivity rate of up to 36.4% has been reported.[5,14,23,28,29,30] The underrepresentation of such cases could be attributed to small sample sizes, making it difficult to draw statistically significant conclusions and diagnostic challenges due to the difference in disease presentation. Also, regional variances in prevalence and characteristics of the disease in various studies may influence the finding of the study. High smear positivity suggests a higher bacterial load, increasing the risk of transmission to others, and also indicates more advanced stages of the disease, leading to more complications. Our study found a high slit skin smear positivity emphasising the early case detection, early and aggressive institution of treatment, contact tracing, and community education. Our study showed reluctance of 21% of adults and 14.2% of children to undergo biopsy, which indicates a risk of misdiagnosis. Biopsy also helps in assessing the severity of the disease and monitoring treatment progress. Unwillingness to undergo biopsy poses significant challenges in effectively managing leprosy cases and highlights the importance of educating people to address misconceptions of the procedure.
In our study, the treatment default rate in children (27.8%) is almost similar to that of adults (28.9%). A high default rate in children is alarming and could be attributed to side effects of drugs, cultural beliefs, poor socioeconomic strata, and lack of education in understanding the importance of treatment completion. Defaulters remains a significant challenge, particularly among paediatric cases, emphasising the need of implementation of cultural sensitive strategies, targeted interventions, and proper counselling of parents or caregivers regarding importance of completion of anti-leprosy treatment. This can prevent development of resistance, further transmission of disease, and prevention of development of deformity and disability.
The new WHO global strategy is being formed, which is entitled towards zero leprosy defined as zero disease and infection, zero disability, and zero stigma and discrimination. The targets to be achieved by 2030 include zero reporting of new autochthonous cases by 120 countries, 70% reduction in annual number of new cases, and 90% reduction in rate per million population of new cases with grade-2 disability and new child cases. As per reported data of 2019, only 34 countries have reported zero new autochthonous cases and the prevalence of new cases grade 2 disability and new child cases was reported as 1.40 and 7.83, respectively.
Conclusion
Childhood leprosy is still contributing to a large proportion of total case load of leprosy, suggesting a continued high transmission of leprosy in the community. Leprosy in children in our study has shown a high number of cases of type 1 lepra reaction, paralytic deformities, disability, and pure neuritic leprosy. There had been multiple descriptive studies focussing on childhood leprosy; however, there is a gap in our understanding as no efforts have been made to directly compare paediatric and adult leprosy. Such a comparative analysis as in our study could deepen our knowledge of how the disease behaves across different age groups. Our study highlights the need of early detection, timely intervention, and community awareness to reduce the stigma and discrimination associated with the disease and improving the quality of life of children.
Ethical approval
Ethical approval was taken from institutional ethics committee- Human research, university college of medical sciences before the commencement of the study.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
- 1.WHO. Global leprosy (Hansen disease) update, 2022: New paradigm-control to elimination. Wkly Epidemiol Rec. 2023;98:409–30. [Google Scholar]
- 2.WHO. MDT Questions and Answers, Action Programme for the Elimination of Leprosy, Revised 1997. [[Last assessed on 2024 Aug 14]]. Available from https://iris.who.int/bitstream/handle/10665/63612/WHO_LEP_97.8.pdf?sequence=1&isAllowed=y .
- 3.Ministry of Health and Family Welfare, Government of India, 2023. Leprosy Mukt Bharat- Press Information bureau. Available from: https://pib.gov.in/PressReleasePage.aspx?PRID=1894687#: ~: text=Highlighting%20the%20achievements% 20of%20the,to%205.52%20in%202021%2D22 .
- 4.Global leprosy (Hansen disease) update, 2019: Time to step-up prevention initiatives. Wkly Epidemiol Rec. 2020;95:417–40. [Google Scholar]
- 5.Balai M, Agarwal C, Gupta LK, Khare AK, Mittal A. Current scenario of childhood leprosy at a Tertiary Care Hospital in Southern Rajasthan. Indian Dermatol Online J. 2017;8:494–5. doi: 10.4103/idoj.IDOJ_8_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Shetty VP, Ghate SD, Wakade AV, Thakar UH, Thakur DV, D'Souza E. Clinical, bacteriological, and histopathological characteristics of newly detected children with leprosy: A population based study in a defined rural and urban area of Maharashtra, Western India. Indian J Dermatol Venereol Leprol. 2013;79:512–7. doi: 10.4103/0378-6323.113081. [DOI] [PubMed] [Google Scholar]
- 7.Jain S, Reddy RG, Osmani SN, Lockwood DN, Suneetha S. Childhood leprosy in an urban clinic, Hyderabad, India: Clinical presentation and the role of household contacts. Lepr Rev. 2002;73:248–53. [PubMed] [Google Scholar]
- 8.Sehgal VN, Sehgal S. Leprosy in young urban children. Int J Dermatol. 1988;27:112–4. doi: 10.1111/j.1365-4362.1988.tb01284.x. [DOI] [PubMed] [Google Scholar]
- 9.Horo I, Rao PS, Nanda NK, Abraham S. Childhood leprosy: Profiles from a leprosy referral hospital in West Bengal, India. Indian J Lepr. 2010;82:33–7. [PubMed] [Google Scholar]
- 10.Palit A, Inamadar AC, Desai SS, Sharma P. Childhood leprosy in the post-elimination phase: Data from a tertiary health care hospital in the Karnataka state of South India. Lepr Rev. 2014;85:85–92. [PubMed] [Google Scholar]
- 11.Sasidharanpillai S, Binitha MP, Riyaz N, Ambooken B, Mariyath OK, George B, et al. Childhood leprosy: A retrospective descriptive study from Government Medical College, Kozhikode, Kerala. Lepr Rev. 2014;85:10–100. [PubMed] [Google Scholar]
- 12.Prasad PV. Childhood leprosy in a rural hospital. Indian J Pediatr. 1998;65:751–4. doi: 10.1007/BF02731059. [DOI] [PubMed] [Google Scholar]
- 13.Ghunawat S, Relhan V, Mittal S, Sandhu J, Garg VK. Childhood leprosy: A retrospective descriptive study from Delhi. Indian J Dermatol. 2018;63:455–8. doi: 10.4103/ijd.IJD_99_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Dogra S, Narang T, Khullar G, Kumar R, Saikia UN. Childhood leprosy through the post-leprosy-elimination era: A retrospective analysis of epidemiological and clinical characteristics of disease over eleven years from a tertiary care hospital in North India. Lepr Rev. 2014;85:296–310. [PubMed] [Google Scholar]
- 15.Joy N, Patnaik S, Nayak S, Rout AN. Childhood leprosy in post elimination era: A clinico-epidemiological prospective observational study from India. Indian Dermatol Online J. 2023;14:829–38. doi: 10.4103/idoj.idoj_544_22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Babu A, Bhat MR, Jayaraman J. Childhood leprosy in the postelimination era: A vision achieved or a concern growing at large. Pediatr Dermatol. 2018;19:26–30. [Google Scholar]
- 17.Sehgal VN, Joginder Leprosy in children: Correlation of clinical, histopathological, bacteriological and immunological parameters. Lepr Rev. 1989;60:202–5. doi: 10.5935/0305-7518.19890026. [DOI] [PubMed] [Google Scholar]
- 18.Kaur I, Kaur S, Sharma VK, Kumar B. Childhood leprosy in Northern India. Pediatr Dermatol. 1991;8:21–4. doi: 10.1111/j.1525-1470.1991.tb00833.x. [DOI] [PubMed] [Google Scholar]
- 19.Singal A, Sonthalia S, Pandhi D. Childhood leprosy in a tertiary-care hospital in Delhi, India: A reappraisal in the post-elimination era. Lepr Rev. 2011;82:259–69. [PubMed] [Google Scholar]
- 20.Pradhan S, Podder I, Chowdhury SN, Banerjee G, Bandyopadhyay D. Clinico-epidemiological spectrum of childhood leprosy in post-elimination era: A multi-centre, cross-sectional study from West Bengal. Indian J Lepr. 2021;93:193–202. [Google Scholar]
- 21.Sehgal VN, Rege VL, Mascarenhas MF, Reys M. The prevalence and pattern of leprosy in a school survey. Int J Lepr Other Mycobact Dis. 1977;45:360–3. [PubMed] [Google Scholar]
- 22.Selvapndian AJ, Muliyil J, Joseph A, Kuppusamy P, Martin GG. School-survey in a rural leprosy endemic area. Lepr India. 1980;52:209–16. [PubMed] [Google Scholar]
- 23.Burman KD, Rijall A, Agrawal S, Agarwalla A, Verma KK. Childhood leprosy in eastern Nepal: A hospital-based study. Indian J Lepr. 2003;75:47–52. [PubMed] [Google Scholar]
- 24.Nair SP. A clinico-epidemiological study of pediatric leprosy in the urban leprosy center of a tertiary care institute. Indian J Paediatr Dermatol. 2017;18:24–7. [Google Scholar]
- 25.Jain M, Nayak C, Chokkar R, Aderao R. Clinical, bacteriological, and histopathological characteristics of children with leprosy: A retrospective, analytical study in dermatology outpatient department of tertiary care centre. Indian J Paediatr Dermatol. 2014;15:16. [Google Scholar]
- 26.Chaitra P, Bhat RM. Postelimination status of childhood leprosy: Report from a tertiary-care hospital in South India. Biomed Res Int 2013. 2013 doi: 10.1155/2013/328673. 328673. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Rao R, Balachandran C. Multiple grade II deformities in a child: Tragic effect of leprosy. J Trop Pediatr. 2010;56:363–5. doi: 10.1093/tropej/fmp138. [DOI] [PubMed] [Google Scholar]
- 28.Solanki AD, Barot JP, Patel JH, Patel NM, Patel D, Nagrani N, et al. Measurement of quality of life in patients of leprosy attending outdoor patient department at tertiary care center of Ahmedabad: A cross sectional study. Indian J Lepr. 2020;92:139–45. [Google Scholar]
- 29.Sakral A, Dogra N, Dogra D, Sharma K. Clinical and epidemiological trends in childhood leprosy: A 20-year retrospective analysis from a tertiary care hospital in Jammu, North India. Indian J Dermatol Venereol Leprol. 2022;88:755–60. doi: 10.25259/IJDVL_1326_20. [DOI] [PubMed] [Google Scholar]
- 30.Rao T, Talluri A. Clinico-epidemiological study of childhood leprosy in post elimination period at a tertiary care hospital. Int J Contemp Med Res. 2019;6:1–3. [Google Scholar]