According to the World Health Organization (WHO), isolated pockets of leprosy remain within nine countries. However, even casual conversations during the course of developing this photographic essay indicate that there may be underreporting of the illness in regions of the Indian subcontinent and elsewhere.1 The fact is, leprosy remains an enigmatic but treatable infectious disease, and multidrug therapy and early detection remain the keys to its control and elimination.
This essay includes photographs I compiled during my travels over the last 15 years. Most of the images portray more advanced disease. However, readily available guidelines can be used to help prevent the advancement of disease and the development of physical disability.2 Of particular importance is care of the feet, hands, and eyes—these problems have prevented the integration of leprosy patients into their communities for more than 2,000 years. The images portray problems with all three areas.
With an incubation period that may occur over many years, a possible reemergence related to human immunodeficiency virus infection, and a natural background reservoir of the illness, leprosy should lead us to consider the meaning of elimination. According to WHO, “Elimination of leprosy as a public health problem is defined as a prevalence rate of less than one case per 10,000 persons.”3 Now that leprosy is on the verge of being “eliminated,” it is important for us to consider another global public health success, and for the nations of the world to make one last push to eradicate the disease permanently.
However, even if leprosy is eliminated, it will remain a public health problem for many decades. The illness may be accompanied by significant disability, but it is difficult to find data on the true incidence of leprosy-related disability. It appears that in some instances, the level of nerve damage and disability may progress despite adequate treatment. Thus, disability prevention may become another marker as to how well communities are treating leprosy and its complications.
This may be particularly true as leprosy control programs are integrated into primary medical care. For example, multidrug therapy has controlled the overall prevalence of eye complications. However, age-related cataracts have become a leading cause of blindness among leprosy patients. Another cause of blindness is exposure keratitis and corneal anaesthesia.4,5
Case detection and the maintenance of data on new and old cases remain important factors in assuring that all segments of society are reached. Early drug therapy and prevention of disability are also important.6 In some areas, the isolation of leprosy patients remains problematic, and living standards may be low.7 In one instance, I witnessed treatment with homeopathic remedies for which evidence of efficacy could not be provided.
There has been considerable success toward the control of leprosy. But it will be necessary to maintain funding and programs if we are going to continue to make progress.
Multidrug therapy has greatly decreased the morbidity associated with leprosy, but even with this therapy, nerve damage sometimes results in disabling loss. Injury to the feet is one of the main sites.
Bacteria (Mycobacterium leprae) attack peripheral nerves, such as those that control blinking of the eyes. The loss of this reflex renders the eye unprotected from injury and dries the surface. It can eventually result in loss of sight and even loss of the eye.
Depigmentation, scaling, and nodules are classic dermatologic manifestations of leprosy. In fact, it is considered primarily a dermatologic disease.
Leprosy may result in considerable disability. The loss of mobility may result from lack of sensation, limb loss, or visual impairment.
It is increasingly important for leprosy patients to integrate into their communities. If treated early, leprosy does not need to result in disability.
In cases of advanced disease, surgical intervention may provide some relief. In this image, extensor motion is being given back to a person by tendon reconfiguration. Though drastic, there may be some value to tertiary prevention of more advanced sequelae of leprosy.
REFERENCES
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