Leprosy is a complex chronic infectious illness that is dependent on an individual’s immunologic response to the causative organism Mycobacterium leprae. A new species, Mycobacterium lepromatosis, was discovered in 2008, known to cause a unique form of leprosy, namely diffuse lepromatous leprosy endemic to Mexico 1. The disease involves any organ or system; however, skin, peripheral nerves, mucosa of the upper respiratory tract, and the eyes are mostly affected. Leprosy is classified as paucibacillary or multibacillary (MB), according to the bacterial load. The transmission being attributed primarily to close contact with untreated MB cases. Untreated leprosy can cause progressive and permanent damage and deformity, particularly to the skin, nerves, limbs, and eyes. Surveillance, early detection, diagnosis, treatment with multidrug therapy (MDT), and follow-up remain the key elements in controlling the disease 2.
In the 1980s, the WHO initiated the Leprosy Elimination Project that was due by the year 2000. The goal was to reach a prevalence of less than one case in a population of 10 000 individuals in any country. Although the target was not met and the aimed date was extended to the year 2005, substantial progress has been made, with 98 of the 122 countries with leprosy reaching this elimination goal and a reduction in the global prevalence by 68% (more than 14 million cases have been cured) 3.
The enhanced global strategy emphasizes reducing grade 2 disabilities among new cases; thus, it is important that cases be detected early and a course of MDT be completed in a timely manner 4.
The aim of this work was to study the epidemiology of leprosy in Sharkia governorate, a representative of both rural and urban communities, Egypt, at a national level to highlight the effectiveness of the leprosy control program during the period from 1 January 2000 to 31 December 2010. Sharkia governorate is located in the eastern part of the Egyptian Delta region, with 5 340 058 inhabitants in 2006, representing 7.4% of Egypt’s population (72 579 030) at that time.
Patients and methods
This is an epidemiological retrospective study carried out by reviewing records of all leprosy patients in Sharkia governorate from 1 January 2000 to 31 December 2010. The data sources were the Zagazig Leprosy and Dermatology Clinic and the Leprosy Control Unit of the Ministry of Health and Population (medical areas in the governorate where leprosy patients are referred and given specific therapy).
According to the WHO, grading of disabilities was as follows 2:
- Hands and feet:
- Grade 0: no anesthesia, visible deformity, or damage.
- Grade 1: anesthesia present, but no visible deformity nor damage.
- Grade 2: visible deformity and/or damage present.
- Grade 0: no eye problem due to leprosy or evidence of visual loss.
- Grade 1: eye problems due to leprosy present, but vision not severely affected as a result (vision>6/60, can count fingers at 6 m).
- Grade 2: severe visual impairment (vision≤6/60, inability to count fingers at 6 m), lagophthalmos, irridocyclitis, and/or corneal opacities.
Data entry was performed using the SPSS program, version 10 (SPSS Inc., Chicago, Illinois, USA). Statistical analyses were carried out on Windows 1998 installed on a personal computer compatible with an IBM computer. Differences between the groups were tested using the χ2-test and Student’s t-test. A P-value of less than 0.05 was considered significant. A running record of new case detection (NCD) during the studied period was maintained using run charts (Microsoft Excel 2007). With less than 20 points, the presence of a run of at least 7 data points on the same side of the median, ignoring the point on the median, is considered to be a ‘shift’. At least six consecutive decreases or increases in the data, ignoring the point that repeated the preceding value, are considered to be a ‘trend’ 5. Either a ‘shift’ or a ‘trend’ is indicative of the effectiveness of the control program.
During the study period (2000–2010), the NCD in Sharkia governorate was 488 cases, accounting for 3.8% of the total number of NCD in Egypt (12 260) during the same time period. Table 1 shows the details of NCD during each of the study years. The running record of NCD in Egypt during the studied period, maintained using a run chart, revealed a consecutive decrease starting from the year 2004 until 2010, achieving a shift of 7/11 data points below the median and a trend of 6 data points (Fig. 1), indicating the effectiveness of the leprosy control program in Egypt. In Sharkia governorate, NCD showed a shift of only 6 points below the median starting from the year 2005 (Fig. 2), indicating the tendency toward the effectiveness of the leprosy control program, although NCD began to rise in 2010.
No significant difference was found in terms of the sex distribution, according to which 272 of 448 new cases were men (55.7% men and 44.3% women), and the percentage of new cases involving children below 14 years ranged from 6.1–26.3%, with the highest percentage (15.8, 26.3, and 12.8%) in the years 2008, 2009, and 2010, respectively. The number of NCD with positive contact history throughout the study was 210, constituting 43% of the total NCD in Sharkia governorate.
Among new cases, grade 0 disability was detected in 73.8%, whereas 20.9% of cases were of grade 1 and 5.3% were of grade 2.
NCD was either passive, through notification (58.2%) or voluntary reporting (20.1%), or active, through contact surveys (21.5%) or mass surveys (0.2%). Ninety-three percent of the newly detected cases were MB, reaching a peak (98 and 97.7%) in the years 2002 and 2007 respectively.
Reviewing the data from 1 January 2000 to 31 December 2010, there were 991 patients under treatment (old and new cases) in Sharkia governorate, of whom 556 patients completed therapy (516 MB and 40 paucibacillary) with no relapse. Only three cases during the study showed a relapse in the years 2000, 2003, and 2010 (Table 2).
NCD in Egypt showed improvement during the 11-year period (from 1561 in the year 2000 to 680 in the year 2010); in contrast, NCD in Sharkia governorate did not show the same pattern of improvement (from 55 in the year 2000 to 47 in the year 2010). These data revealed an effective leprosy control program in Egypt as a whole, whereas it was not as effective in Sharkia. In comparison, Kalyubia governorate showed an improvement in two studies conducted in 1996 6 and 2007 7. In the first study, the NCD was 349 during the period from 1992 to 1995 6, whereas Wadie 7 found that the NCD dropped from 86 cases in the year 2000 to 45 cases in the year 2006.
With a more detailed perspective, NCD in Sharkia governorate showed an apparent increase in 2010. This raises an important question: Was it a true increase or was it because of increased awareness, reporting, and availability of facilities in the last few years?
The actual NCD and NCD rate provide a better estimate of leprosy burden as compared with the number of registered cases 8. A false impression of the low number of registered cases could be created because of shortening of the duration of therapy (12–18 months), which was started in the early 1990s by several studies comparing both regimens (12–18 vs. 24 months MDT in MB patients) 9. Another explanation is the removal of cured and MB patients who stopped therapy before completing the stipulated 24-month period from the registers, rather than a reduction in the transmission of the disease 8.
MB patients are considered more infectious, thus more likely responsible for disease transmission 10, which is why it is important to know the proportion of MB patients among newly detected cases. Several studies reported a high incidence of MB cases in Dakahlia, Kalyubia, and Sohag governorates (95.3, 95.7, and 92.7%, respectively) 2,7,11, similar to 93% in Sharkia governorate reported by this study. In the year 2010, the number of MB cases detected in Egypt was 601 cases among 680 newly detected cases (88.38%) 4. It was only in Gharbia governorate that MB cases comprised 49.52% of 622 newly detected cases in a study conducted during the period from 1994 to 2005 12. Almost all observations point to the high incidence of MB leprosy in Egypt. This high proportion may indicate a delay in detection of leprosy; however, it may also be influenced by changes in the clinical definition of MB leprosy (a case with ≥5 skin lesions) proposed by the WHO since the introduction of MDT 10.
Affection of children reflects recent transmission of leprosy: ‘the number and proportion of these cases are important epidemiological indicators’ 13. In the present study, the proportion of children in Sharkia governorate ranged from 6.1–26.3%, reporting the highest proportions in the last 3 years of the study (2008–2010). In Egypt, in year the 2010, the number of children was 52/680 among newly detected cases (7.6%) 4. These results were comparable with the results in Kalyubia 7, Gharbia 12, and Sohag 2 governorates where 11, 8.04 and 10% of the newly detected cases, respectively, were children. The high percentage of children may be attributed either to the increased awareness, continuous surveillance and early detection of cases or, from another perspective, to the increased disease transmission confirmed by the high percentage of MB cases during the study. This indicates that leprosy control needs a continuous improvement project to assure early diagnosis with prompt treatment.
In a study conducted in Sohag governorate during the period from 2004 to 2008, a high percentage (36.5% of 587 newly detected patients) of new cases with a history of positive contact to old patients 2 was reported. This large number of NCD in a short period was not noticed in this study. Over a period of 11 years, only 43% of the 488 newly detected cases had a history of positive contact to old patients.
The percentage of female patients among NCD reported in Egypt and by studies conducted in different governorates is not uniform. In Egypt, in year 2010, the percentage of women affected was 35.74% (243 cases) of 680 NCD 4. In an earlier study in Gharbia governorate, female patients constituted 55.79% of 622 newly detected cases 12. In the present study, female patients constituted 44.3% of NCD, whereas in several other studies they constituted a lower percentage 2,6. It is not clear whether the low percentage of female patients affected reflects a true difference or whether it is influenced by case ascertainment associated with an unequal availability of health services for both men and women. Other explanations have been postulated such as those suggesting that women in general are poorly represented in hospital statistics because of socioeconomic and cultural difficulties 14.
Although grade 1 disabilities represent a high percentage, the proportion of grade 2 disabilities is an important indicator as it can be reliably measured and it reflects delays in case detection. Most epidemiological studies on disabilities are based on cross-sectional surveys 10. In Egypt, in the year 2010, 55 patients with grade 2 disabilities were detected among 680 newly detected cases 4. Grade 2 disabilities accounted for 21.4% of new cases detected in Sohag governorate 2, in comparison with 5.3% in this study.
In Kalyubia governorate 6, passive detection was 66.5% through notification and 32.7% through voluntary attendance to the unit of leprosy control. Only 0.8% of cases were detected actively through contact surveys implemented by the unit. This is in comparison with NCD in this study, which was either passive through notification (58.2%) and voluntary reporting (20.1%) or active through contact surveys (21.5%) or mass surveys (0.2%). An improvement in awareness and survey programs may account for the difference in active case detection.
Only three cases showed relapses during the study in the years 2000, 2003, and 2010. One of the best methods for evaluation of the effectiveness of a chemotherapeutic regimen is the monitoring of relapses after the completion of the treatment protocol 15,16.
Although great achievement is apparent in controlling leprosy and reducing the burden of the disease in Egypt, Sharkia needs a stricter implementation of the control program. Early case detection and prompt treatment with MDT remains the cornerstone of control programs. The present study in Sharkia governorate highlights the importance of prophylaxis, follow-up, and early detection of disease in the group of patient contacts. This needs to be ensured by strengthening the integration with general health services, active staff members and co-workers, continuous surveillance, and sufficient funds.
The authors thank Professor Dr Wedad Zoheir Mostafa (Professor of Dermatology, Faculty of Medicine, Cairo University) for her help, support, encouragement, and creative input in preparing this article.
Conflicts of interest
There are no conflicts of interest.
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