Leprosy in children is an indicator of ongoing disease transmission. The frequency of occurrence of this chronic disease in children is one of the important epidemiological indexes to determine the level of transmission of the disease. Leprosy in children forms an important link in the natural evolution and the epidemic profile of the disease.
Children are more susceptible to leprosy due to their naïve immunity and close family contacts. The endemic areas of leprosy are usually in underdeveloped and developing countries where children live in low socioeconomic and unhygienic conditions. In the endemic areas, the peak age of incidence is in the age group of 10–14 years. India has achieved leprosy elimination in 2006. The prevalence rate was 0.69/10,000 population in April 2015. According to the NLEP annual report, 2014–2015, a total of 11,365 child cases were recorded, indicating the child case rate of 0.88/100,000 population. In the year 2015–2016, the proportion of new childhood leprosy cases was 8.94%. Eleven thousand three hundred eighty-nine child cases were recorded, indicating the child case rate of 0.89/100,000 population. During the year 2017, the proportion of child cases was 8.7%.
A study conducted by Chaitra and Bhat in a tertiary care hospital of South Karnataka showed the percentage of childhood leprosy cases at 12.12% in 2013, 8 years post elimination. A similar retrospective study conducted at All India Institute of Medical Sciences, Bihar, during 2014–2018, showed a child proportion rate of 9.31% among total leprosy patients. This tertiary care center at a semiurban area of Raichur is not so endemic for leprosy. Hence, we wanted to study the proportion and profile of pediatric leprosy cases in this area. This study findings may help us to effectively achieve the Global Leprosy Strategy targets.
- Primary – To estimate the proportion of childhood leprosy cases attending the tertiary care center of North Karnataka
- Secondary – To study the clinical and epidemiological profile of childhood leprosy in our area.
This is a cross-sectional observational study conducted retrospectively at Raichur Institute of Medical Sciences, Raichur. Institutional ethics committee approval was obtained with No. RIMS/IEC/Teach. Staff/20–21/01 dated December 29, 2020. Recorded secondary data of leprosy patients were taken from the past records for the period from January 2017 to December 2020 (4 years). Only new cases with leprosy in the age group of 0–14 years reported during the study period were included. All patients with childhood leprosy had undergone detailed clinical examination, split-skin smear, and skin biopsy. Those patients who are on multidrug therapy for leprosy and defaulters were excluded. Diagnosis of leprosy was based on Ridley–Jopling classification and IAL classification. The details of variables such as age, sex, history of family contact, number of lesions, nerve involvement, smear positivity, histopathological diagnosis, type of disease, and any complications such as lepra reactions or deformities were noted and tabulated in an Excel spreadsheet from Microsoft Office 2019. Clinicobacterial and clinicohistopathological correlations were carried out. Depending on the number of lesions and the number of nerves enlarged, patients were classified as paucibacillary (PB) and multibacillary (MB) types as per the WHO guidelines. Data were analyzed for descriptive statistical analysis using percentage and proportion.
A total of 576 new cases of Hansen’s disease were diagnosed during the 4-year study period. Among them, 55 patients were in the age group of 0–14 years. Year-wise distribution of childhood leprosy cases with proportion is shown in Table 1. Majority of the cases (36) were in the age group of 10–14 years and two patients below 4 years. Male and female were equally affected [Table 2]. Only 20% of patients gave a history of contact with a known case of leprosy, usually parents and grandparents.
Single lesion presentation was seen in 52.7% of patients and 2–5 lesions in 34.6%. Five patients had >5 lesions and two patients of pure neuritic Hansen’s no skin lesions. Face was the most common site for the hypopigmented patch, followed by other exposed areas such as the upper extremities and lower extremities. Two patients presented with only neural involvement without any skin lesions. About 38.2% of patients had features of nerve enlargement; the ulnar nerve was the most commonly involved [Table 3]. Borderline tuberculoid leprosy (BT) was the most common type seen in 76.36% of patients. About 12.7% were in the spectrum of indeterminate spectrum [Table 4]. Majority of the patients (49) were of the PB type. Only six patients had MB type of leprosy.
Smear positivity was seen in five patients in the age group of 10–14 years belonging to the spectrum of borderline lepromatous (BL), lepromatous leprosy (LL), and pure neuritic leprosy [Table 5]. A clinicopathological correlation was established in 90.09% of patients. Histopathology was consistent with clinical diagnosis in 88.09% of patients with BT. Five cases which were clinically diagnosed as BT were found to be indeterminate on histopathological examination [Table 6]. Fite-Faraco stain was positive for Mycobacterium Leprae in five biopsy samples.
Six patients developed lepra reactions during treatment with multidrug therapy. Five patients suffered from type I reactions and one patient with recurrent type II reactions. Visible deformities were observed in three cases (5.45%). They were partial claw hands and wasting of hypothenar eminence.
Leprosy is an important problem in the pediatric age group. Early detection and treatment can prevent complications, such as reactions and deformities. According to the Global Leprosy Strategy, the target for the year ending 2020 is that the number of children diagnosed with leprosy and visible deformities to be reduced to zero.
In the present study, children represent 9.54% of all diagnosed cases of leprosy, reflecting a slightly higher level of disease transmission in this region. This proportion was an average of 4 years. We observed a declining trend in the child proportion rate, which was 11.61% in the year 2017 and 6.45% in 2020 [Table 1]. In endemic areas, the proportion of childhood leprosy cases is more, which indicates a higher level of transmission and prevalence. In India, leprosy was declared as eliminated in 2006 when the prevalence rate reached <1/10,000 population. Post elimination, there has been wide variation in the proportion of childhood leprosy cases. The percentage of childhood leprosy cases ranged from 5.7% to 16% in various studies. In a study conducted by Gitte et al. in 2015 in Chhattisgarh, an area highly endemic for leprosy reported 16% of childhood cases among the total leprosy patients.
In this study, majority of patients were between 10 and 14 years of age which is a similar observation by many workers,[9-11] indicating that the disease might have been contracted in early childhood, the disease takes much longer to manifest because of a prolonged incubation period. In addition, delay in diagnosis may be another contributing factor.
In this study, male and female are equally affected (male:female ratio: 1.04:1), which is similar to the observation in various other studies. It is likely that in infants and children, the opportunity to contract infection seems to be equal and this may reflect equal sex prevalence. Few other studies showed more prevalence in males when compared to females, which may be due to more physical activity and exposure.
PB leprosy formed the major group (89.09%), in which BT was the most common type. This finding in conformity revealed a low rate of LL in children. A similar finding was observed in a study by Nair et al., who reported 81.66% of PB cases in children. We observed that patients with MB type (10.91%) of leprosy increased with age. This could be explained by the fact that MB leprosy generally takes more time to develop. Gitte et al. reported a higher percentage of MB leprosy (59.89%) than PB leprosy. Arif et al. also reported a similar finding with 58.62% of MB leprosy in childhood leprosy. A recent study by Gupta et al. in 2019 reported an almost equal percentage of MB (54.16%) and PB (45.85%) patients.
The majority of the children reported with a single hypopigmented patch without nerve involvement (61.8%). The patch was located on an exposed site of the body, most commonly face a finding well supported by other studies. Solitary lesion was the most common clinical presentation seen in 61.11% as reported by Chaitra et al. and 64.4% in a study by Babu et al. This could be explained by M. Leprae’s predilection for the cooler areas of the body.
In the case of children, the source of infection many times is a case of untreated MB leprosy patient within the family or the community. In our study, a history of contact with a known case of leprosy was observed in 20% of the cases. It is important to conduct a periodic examination of contacts of adult patients. Sachdeva et al. reported 35% of children had household contact, emphasizing the field visits to trace the contacts. The risk of acquiring leprosy increases by four times if there is a contact in the neighborhood.
Neural involvement was observed in 38.2% of the patients at the time of presentation. Ulnar nerve was the most commonly involved. Peripheral nerve thickening was present in 45% of cases as found by Nair. Multiple neural involvements may increase the risk of deformities.
Clinicohistopathological correlation was established in 50 (90.9%) cases. In the study by Babu et al., 78.1% of the cases showed correlation with respect to clinical and histopathological diagnosis.
The majority of the patients presented with negative slit-skin smears. This observation is consistent with the fact that the majority of subjects in the present study had PB leprosy. Only 9% of the cases showed smear positivity which included BL, LL, and one case of pure neuritic Hansen’s disease. In the study by Palit and Inamadar, the prevalence of smear-positive leprosy in children was 8.19%.
The prevalence of lepra reaction was 10.9% in this study. In other studies, it ranged from 1.36% to 29.7%.
Deformities and disabilities are rare in children compared to adults. Deformities were observed in three (5.45%) cases presenting as partial claw hand and wasting of the hypothenar eminence.
Adverse reactions to multidrug therapy were observed in 3 (5.45%) cases.
This study showed a decreasing trend in the proportion of pediatric leprosy cases year by year. The most common type of childhood leprosy was PB type. In addition, reactions and deformities were low. To achieve the global leprosy target of zero childhood leprosy cases and to prevent deformities, there is a need for early diagnosis, contact tracing, proper community surveillance, and regular follow-up. Proper and periodic training of school health officers to detect cases early and prompt referral to the specialist should be done. Stress for treatment completion in adults also helps in preventing the transmission.
Strengths of this study – this study shows the trend in the proportion of childhood leprosy cases over a period of 4 years so that tertiary care services can be planned effectively. Limitations – this is a retrospective study. In a hospital-based study, prevalence cannot be estimated. The number of cases reported to tertiary care hospitals may not represent actual cases in the community.
Declaration of consent
The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s) of the patient. In the form the parent(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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