|Year : 2015 | Volume
| Issue : 1 | Page : 55-59
|Leprosy scenario at a tertiary level hospital in Delhi: A 5-year retrospective study
Namrata Chhabra, Chander Grover, Archana Singal, Sambit Nath Bhattacharya, Ramandeep Kaur
Departments of Dermatology, Venereology and Leprology, University College of Medical Sciences and GTB Hospital, University of Delhi, New Delhi, India
|Date of Web Publication||26-Dec-2014|
420-B, Pocket 2, Mayur Vihar, Phase-1, Delhi - 110 091
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Leprosy has been officially eliminated from India since December, 2005; still, there are districts and blocks reporting high prevalence indicating ongoing transmission. The present study aimed at determining the current clinical profile of leprosy from a tertiary level hospital in Delhi. Materials and Methods: A retrospective, record-based study was carried out on patients diagnosed and registered in the leprosy clinic of a tertiary level teaching hospital in East district of Delhi (April 2007 to March 2012). Data regarding demographic details, clinical features, treatment started and complications was analyzed. Results: A total of 849 patients were registered over a 5-year period, with M: F ratio of 2.3:1. 9.3% were children (ͳ14 years). 54.3% patients were immigrants from adjoining states. Multibacillary leprosy was the most common clinical type (86.9%). Borderline tuberculoid leprosy was the most frequent morphologic type, seen in 56.3% followed by borderline-borderline (1.5%), borderline lepromatous (24.9%), lepromatous leprosy (8.1%), pure neuritic (8.1%), histoid and indeterminate leprosy (0.5% each). 37.4% patients presented in reaction (Type I in 30.4% cases and Type II in 7% cases). WHO grade II deformities were diagnosed in 37.9% with claw hand being the most common paralytic deformity (23.3% cases). Conclusion: Our study offers insight into the current status of the disease in an area of otherwise low prevalence. It is seen that despite statistical elimination, multibacillary disease, leprosy reactions and deformities are commonly seen as presenting manifestations, in contrast to national projected trends. Delhi's unique demography with a high degree of migrant workers, presenting to our center (near border location) could be a possible contributing factor towards these aberrations. It highlights the need for continuation of targeted leprosy control activities and active case detection.
Keywords: Grade 2 deformity, leprosy reactions, multibacillary disease
|How to cite this article:|
Chhabra N, Grover C, Singal A, Bhattacharya SN, Kaur R. Leprosy scenario at a tertiary level hospital in Delhi: A 5-year retrospective study. Indian J Dermatol 2015;60:55-9
|How to cite this URL:|
Chhabra N, Grover C, Singal A, Bhattacharya SN, Kaur R. Leprosy scenario at a tertiary level hospital in Delhi: A 5-year retrospective study. Indian J Dermatol [serial online] 2015 [cited 2020 Jan 19];60:55-9. Available from: http://www.e-ijd.org/text.asp?2015/60/1/55/147793
What was Known?
- Leprosy has been officially eliminated from India (<1 case per 10,000 population) in the year 2005. However, many new cases continue to be reported.
- Many recent studies have tried to focus on the urban leprosy scenario. Despite the falling trend in new case detection, reported in urban areas the leprosy burden in high endemic zones in these areas is still high.
| Introduction|| |
Leprosy is caused by Mycobacterium leprae, a slow growing mycobacterium, manifesting as damage to the skin and peripheral nerves. India has achieved great success in eliminating the disease (prevalence rate being 0.68/10,000 in March, 2012); however, even in states/UTs that have achieved elimination, a few districts and blocks continue to have a prevalence >1/10,000. The National Capital Territory of Delhi achieved elimination in 2008; yet, there are high endemic zones in Delhi and an almost constant trend of new case detection in this state has been reported even in recent studies by Kumar et al. and Singal et al. , To assess the current situation of leprosy and to address the possible loopholes in the running program, data from referral clinics is an essential pre-requisite. Hence, the present study was performed to analyze the profile and magnitude of leprosy patients presenting to our tertiary level referral center.
| Materials and Methods|| |
A retrospective data analysis of all leprosy cases registered at the Leprosy Clinic of Guru Teg Bahadur Hospital, Delhi from April 2007 till March 2012, was carried out. Our hospital is situated in North East District of Delhi, catering to the East Delhi population as well as patients from adjacent states, especially Western Uttar Pradesh. Case detection was based on voluntary reporting rather than active case finding or surveys.
The data was analyzed according to age, sex, residence, history of contact, type of leprosy, leprosy reactions, and deformities. Patients were classified as per Ridley Jopling classification,  and as per the criteria laid down under NLEP and treated accordingly. As per WHO classification,  the disease was classified as multibacillary (MB) if there are six or more lesions and/or more than one nerve involvement. Our data was compared with the national averages.
| Results|| |
A total of 849 new cases of leprosy were registered during the study period of 5 years. The year-wise distribution can be seen in [Table 1]. The mean age of patients was 32.08 ± 15.46 years. A majority of the patients (49.3%) were in the middle age group (21-40 years) [Figure 1]. A total of 79 (9.3%) of these patients were children. There was a male preponderance with M:F ratio of 2.3:1. The majority of patients were immigrants (54.3%, n = 461), mainly from Uttar Pradesh (40.3%, n = 342) and Bihar (12%, n = 102). The regional distribution of patients has been depicted in [Table 2]. Only 50 patients (5.9%) gave a history of contact with a leprosy patient within the household. The definition of household contacts included family members of leprosy patients, living under the same roof, and partaking in meals from a common kitchen.
MB leprosy was the most common clinical type of leprosy encountered in 86.9% patients (n = 738). According to the RJ classification, 82.8% (n = 703) patients were in the borderline spectrum. Borderline Tuberculoid (BT) was the most frequent morphologic type, seen in 56.3% (n = 478) followed by Borderline (BB) in 1.5% (n = 13), Borderline Lepromatous (BL) in 24.9% (n = 212) and Lepromatous (LL) in 8.1% (n = 69) patients. Additionally, special types of leprosy were recorded in 9.06% patients (n = 77) with Histoid, PNL and indeterminate forms in 4 (0.5%), 69 (8.1%) and 4 (0.5%) patients, respectively [Figure 2]. Among BT cases, 52.5% had single skin lesion, 30.3% had two to five lesions and 17.1% patients had more than five skin lesions.
|Figure 2: Clinical presentation of the newly registered leprosy patients|
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Clinically thickened peripheral nerve enlargement was recorded in 88.9% patients (n = 755). The ulnar nerve was the most commonly thickened nerve seen in 72.9% followed by common peroneal nerves in 57.9%, posterior tibial nerves in 47.3% and radial cutaneous in 41.7% patients. Only 173 BT patients (36.2%) had less than or equal to 1 nerve involvement.
Biopsy records were available for 92.36% (784/849) cases. BT leprosy was the most common histological diagnosis. A clinico-histopathological correlation was observed in 618 out of 784 cases (78.8%) with 166 cases (21.2%) demonstrating non-specific histological features.
At initial presentation to the leprosy clinic, 37.5% of the patients were seen to be in reaction. Type I reaction (T1R) was present in 30.4% (n = 258) and Type II reaction (T2R) in 7.1% (n = 60) patients. Only two patients presented with delayed reversal reaction. 65.9% of the T1R cases was observed among BT patients, while most of the T2R (96.7%) was seen in lepromatous patients (BL and LL patients). The percentage of leprosy reactions during the study period has been shown in [Table 1].
Neuritis was seen in 41 patients (4.8%), of whom 13 had T1R and 5 had T2R. Ulnar nerve was the most commonly affected nerve (n = 21/41). Three patients presented with ulnar nerve abscess and two patients with greater auricular nerve abscess.
The overall incidence of various deformities of the hands, feet, or eyes (WHO deformity Grade II) was 37.9% (n = 322/849) detected at the time of diagnosis. Claw hand was the most common paralytic deformity seen in 23.3% (n = 198), followed by facial paresis in 11.2% (n = 95), foot drop in 7.6% (n = 65) and median palsy in 3.8% (n = 32) patients. Trophic ulcer was present in 7.5% (n = 64) patients.
Four patients were found to have pulmonary tuberculosis and one patient had disseminated tuberculosis. They were given standard anti-tubercular treatment regimes along with MDT. Three MB cases were found to be HIV positive, of whom two presented with T1R. The important epidemiological indicators were compared with the corresponding NLEP (National Leprosy Eradication Program) figures. The comparison has been shown in [Table 3].
|Table 3: NLEP indicators in present study in comparison with national trends (2007-12) |
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| Discussion|| |
It was reported by Ganpati et al., in 2005, that "the pool of leprosy patients with reaction, neuritis and its sequelae and those needing rehabilitation contributing to the disease burden in the community will far outnumber the active cases needing MDT".  That day has sadly arrived. In our zeal to "eliminate" leprosy, we seem to be reaching a juncture where number of cases is less, but the disease burden is far more. Recent publications by Singal et al. and Prasad et al. reinforce the fact that single-minded focus on MDT, lack of proper fund allocation and integration with General health services is leading to an inadequate control of the leprosy burden. , The health care system may land up repeating the monumental mistakes made earlier with the Malaria eradication programme.  An early divergence of focus as well as funds lead to resurgence of malaria in the 1970s which has till date remained a major public health problem.  In spite of the established fact that leprosy is least infectious and completely curable, the social stigma still lingers and remains a major obstacle to self-reporting and early treatment. Early detection depends almost completely on voluntary reporting which implies awareness of the disease and its treatment facilities. Our data from a tertiary care referral center shows that an early active search for cases may be needed.
In India, the country with largest case load, MDT has brought down the prevalence of disease from 25.9 in 1991 to 0.68 per 10,000 population in March, 2012. However, as seen in the present data, the scenario is far from satisfactory. Delhi represents 1.39% of the population of India, as per the 2011 census,  with a sex ratio of 866 females per thousand males. Delhi achieved elimination of leprosy in 2008-09. However, being an urban area, it poses unique challenges for health services management. The challenges include social, cultural and economic inequalities and constraints that make vulnerable population segments unaware of or unable to access services. This situation is further complicated by rapid industrialization and increasing density of migrant population in slums. All this contributes to high endemic zones within the city, which add new cases to our national leprosy data. As per 2001 census, the states sending maximum migrants to Delhi are Uttar Pradesh and Bihar which contribute 40.96% and 19.52% of total migration during 1991-2001, respectively. Out of the total migration to Delhi, 69% are from rural areas, while 31% are from urban areas, the predominant reason being work/employment.
In this study, the total number of new cases was 254 in 2007 and decreased to 117 in 2011. The annual new case reporting overall shows a gradual decline in our set-up [Figure 1]. Majority of the patients belonged to the middle age group (21-40 years), similar to the finding reported by Jindal et al.  The percentage of childhood leprosy was 9.3% which is marginally lower than that reported from another tertiary hospital in Delhi (10.2% in 2009)  and from our institute in a previous study (9.6% by Singal et al.).  Grover et al. have reported a relatively lower incidence of childhood leprosy (7.06%) from a tertiary hospital located in central Delhi. This data indicates that leprosy continues to be transmitted in the community.
The higher male to female ratio (2.3:1) in our series could be due to increased opportunities for contact in males, and lack of social perceptive towards female health care. Additionally, 54.3% of our patients were migrant workers. As mostly males migrate to cities in search of employment, this could be an important factor responsible for higher proportion of males in our study. Such demographic effects on disease prevalence have been reported by other authors as well. ,
A 5.9% rate of household contact in our series is lower than that reported by Jindal et al. (9.2%).  Most of the other studies from India have included neighborhood contacts also and therefore the data could not be compared to ours. Van Beers et al. have shown that risk of a person developing leprosy is four times higher when there is a neighborhood contact and up to nine times higher when the contact is intra-familial.  Further, the risk is higher if contact has the MB form of the disease. Thus, it is important to take detailed contact history and screen family members whenever possible.
The percentage of MB cases (86.9%) in our study was significantly higher than PB cases. The corresponding figure from another tertiary hospital in Delhi (1994-2009) was reported to be 80.57%.  Another retrospective study from Satara district in Maharashtra reported 53.6% MB cases among new cases in the year 2007-08.  The high proportion of MB cases in our study could be a sign of existence of inaccessible pockets of population harboring undiagnosed leprosy patients for a long time.
The most frequent morphologic type in our study was BT (56.3%), which is similar to the observations made by Tiwary et al. (56.9%),  Mahajan et al., and Singh et al. However, a significant number of these BT patients were found to harbor MB disease (77.8% cases, n = 372). It is important to detect features suggestive of MB involvement early. It has been reported that among patients initially diagnosed as PB clinically, up to 38-51% turn out to have MB disease and thus are at risk of under-treatment. ,
A higher rate (78.8%) of clinico-histopathological concordance was found in our patients as compared to 52% reported by Sehgal et al.  and 60.6% by Kumar et al. As proposed by Nadkarni et al.,  a proper selection of optimum lesion for biopsy might have been responsible for the high rate observed in our series.
The high rate of reactions observed in our series was alarming. About 30.4% of patients presented with T1R, which was comparable to that reported by Kumar et al. (30.9%).  Most of other epidemiological studies showed a lower percentage of T1R. ,, Most of T1R was seen in BT leprosy (65.9%) which was a consistent finding present in many studies. ,, T2R was seen in 7.1% patients, which is lower as compared to that reported by Jindal et al. (17.2%).  The patients present to health care facilities when much damage has already occurred. If detected early by trained health care workers, we could hope to prevent this morbidity associated with the disease.
Our study showed a much higher incidence of WHO grade 2 deformity at presentation (30.79%) as compared to that reported by Jindal et al. (17.8%).  This could be commensurate with high rate of the occurrence of T1R in our series, which significantly increases the risk of deformities, especially in MB leprosy. The need to improve early detection of reactions as well as the role of careful neurological examination in patients with T1R to help reduce deformities is clearly highlighted. This is one of the stated strategies in the recently implemented enhanced Global Leprosy Strategy 2011-2015 by national leprosy programs. It aims to reduce the global rate of new cases with Grade-2 disabilities per 100 000 population by at least 35% by the end of 2015, compared with the baseline at the end of 2010 through early detection and improving management of leprosy reactions. 
| Limitations|| |
This was a retrospective data analysis based on departmental records, hence bias in reporting cannot be totally ruled out. We could include only the cases presenting to our own center which happens to be tertiary care referral center. It could be safely assumed that more complicated cases were being recorded. Community-based surveys covering the district population could help clarify this issue. Additionally, our center registered a higher proportion of migrant workers, who reside in Delhi for short periods.
| Conclusions|| |
The experience from our tertiary referral center suggests that though great strides have been made in elimination of leprosy, we still cannot celebrate. The high rate of multibacillary disease or patients presenting with reactions and deformities, as compared to the national averages is a cause for alarm. Its time when we need to consolidate the achievement made and intensify on the aberrations discovered.
Level of Evidence: Level II-3.
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What is new?
- Though the number of new cases registered annually has been decreasing, a much larger share of multibacillary cases is a reason for alarm.
- The high rate of Grade 2 deformity and leprosy reactions at the time of presentation in our patients reinforces the need for early detection, through active case search in the community, rather than relying on voluntary reporting.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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