LESSENING THE BURDEN OF LEPROSY
Still viewed by many as an ancient incurable scourge that leads to physical rejection and deformity, treatment for leprosy has advanced along with the times.
by Jon Nalick
Most people consider leprosy a scourge of Biblical times that only exists today, if anywhere, in third world countries with little access to modern medicines. Although the Bible contains numerous references to leprosy, it remains unclear whether the disease we know by that name today is the same because the Greek root of the word, lepros, refers to spots that are scaly,
scabby or rough, which could refer to any number of illnesses.
But according to Thomas Rea, M.D., USC clinical professor of medicine, the disease remains a serious threat to public health worldwide, occurring in more than half a million people each year, some of them in the United States.
Leprosy, also known as Hansen's disease, is endemic to Texas, Louisiana and Hawaii as well as Mexico, the Caribbean, almost all of South America, Southern Europe, Africa, Asia and Australia, and most of the islands in the Pacific, he says. India, Indonesia and Myanmar account for 70 percent of all the cases in the world.
Rea, who directs the Hansen's Disease Clinic at LAC+USC Medical Center, says the clinic currently tracks more than 500 cases of leprosy, with about 30 new case registrations each year in Los Angeles.
Norman Levan, M.D., former chief of dermatology and a USC professor emeritus, started the clinic in 1962 at the request of state and federal health officials who noted that new cases of leprosy were coming in from Mexico and that the closest treatment clinic was in San Francisco. The USC clinic remains one of only three in California; the other two are located in San Diego and Contra Costra counties.
"Even today, there's not a lot known about leprosy. We know it's caused by a bacterium, but the organisms have never been cultured in the laboratory so it has been difficult to study. The organisms grow only in intact animals," Rea says. "So far, it has been impossible to prove the mode of transmission or the level of exposure needed to contract the disease."
Mycobacterium leprae, which causes the disease, is the only bacterium known to attack the peripheral nerves. The symptoms of the illness include: spots on the skin which can range from a few tiny blotches to hundreds of bumps, pain, tingling, loss of feeling, inflammation, weakness, and a loss of muscle control.
"If left untreated, the disease's progression can be quite serious. It's a common cause of blindness and outside the U.S. it's the leading cause of losing the use of your hands," he says. Within the U.S., arthritis is currently the most common cause of hand function loss.
The disease typically strikes people in their 30s living in areas where leprosy is endemic. Men are twice as likely as women to contract the disease, but race is not a factor in susceptibility, Rea says.
Generally, dermatologists throughout Southern California have a good awareness of the illness and are quick to recognize it. Still, because the disease is relatively rare here, there are times when patients go for as many as two years before receiving the correct diagnosis and beginning treatment.
Most people are naturally resistant to the illness and their bodies can destroy the infection without medical assistance. For those with no resistance, the illness ravages the skin and nerves and can cause crippling lesions and deformities. Most people, however, fall in the middle of the spectrum, where treatment with antibiotics not only can arrest the disease, but may cure it.
Armauer G. Hansen discovered the bacterium that causes leprosy in 1873, and it was the first bacterium to be identified as causing disease in man. However, good treatment for leprosy only appeared in the late 1940s with the introduction of the antibacterial drug dapsone, and its derivatives.
Today, an effective multi-drug treatment includes dapsone, rifampin and clofazimine.
Patients become unable to transmit the disease after taking only a few doses of medication so there is no need to quarantine them. Further, they can generally continue their normal work and other activities uninterrupted during treatment that may last several years.
"You treat the illness with multiple [antibiotic] drugs along the lines of tuberculosis. Some [physicians] think multiple drug therapy is curative of the severe form of the disease, but that is just a projection and has not been proven. In my own opinion, it is a very optimistic projection," he says.
The issue of whether to treat family members of people with leprosy simultaneously remains unsettled, although Rea says the conventional wisdom opposes the practice. The rationale is that prophylactic treatment would prevent few instances of the disease while exposing healthy people to a powerful drug with potential side effects and increasing the chances that a resistant strain of the illness could develop.
Although leprosy can be devastating and disabling, most new patients have relatively little disability and further disability can be prevented if patients are diagnosed and treated early in the course of the disease. Still, Rea says that even though the disease is treatable, the stigma attached to it remains. Often, people are fearful that they will be shunned if others discover their condition.
"Most people are not very happy" when they hear the diagnosis, he says. "The common association is that people with leprosy are afflicted because they did something bad and they are dirty and unclean-so this leads to a 'Why did I get this disease?' attitude because of this misconception."
Levan emphasized that the disease is difficult to transmit and patients need not avoid contact with others. In addition, he said physicians should always shake hands with leprosy patients-especially on their initial visits-to reassure them that their illness does not exclude them from human interaction.
"The stigma of being ostracized because you have leprosy still exists, even among educated patients," says Levan. "The physician needs to reinforce that, with treatment, the patient can lead a normal life."