Abstract

Introduction: The proportion of deformity cases among newly diagnosed leprosy patients and the grade 2 disability rate in a population indicate the efficiency of early detection of leprosy. They also invariably indicate the awareness levels of early signs of leprosy, and access to leprosy services in the community.

Aim: To study the frequency and severity of grade 1 and grade 2 deformity among leprosy cases. To correlate the clinical and socioeconomical factors to emphasize the importance of the health education in prevention of disability.

Materials and Methods: This was an observational study conducted in leprosy OPD of a tertiary care centre in south India between Jan’ 2018 and Dec’ 2018. About 62 diagnosed Hansen cases with deformities were included in the study after thorough clinical examination, routine and special investigations. Data was compiled and analyzed with percentages and ANOVA.

Results: Out of 212 diagnosed leprosy cases, 62 had deformities, thus making disability and deformity index to be 29.2%. Among newly diagnosed leprosy cases, 2 had grade 1 and 3 had grade 2 deformity. Males (69.4%) with lower socioeconomic group (41.9%) were commonly affected than females (30.6%). Lepromatous type of leprosy (32%) and leprosy cases of more than 2 to 5 years duration (47%) were commonly involved. Among the leprosy cases, disability was seen more in Multibacillary type (80.6%) and those involved in manual occupation (70.1%). Hands (77.4%) were more involved than and feet (40.3%). Anaesthetic (82.2%) deformities were more common followed by specific (30%) deformities. Grade 1(56.4%) deformities were most common followed by Grade 2(43.6%) deformities.

Conclusions: The study showed that deformities and disabilities occurred due to delay in early case detection of grade -1 disability, lack of treatment assess and health education. Training the health care workers on diagnosing nerve thickening and nerve function impairment will prevent the progression of grade 1 disability to visible grade 2 disability thereby reducing the number of new leprosy cases with G2D to less than one case per million population.

Keywords: Deformity grade 2, New hansen case, Multibacillary type, Neurological examination.

The current Global Leprosy strategy 2016 – 2020 ‘Accelerating towards a leprosy free world’ aims at consolidating the gains achieved by Multi drug therapy MDT in leprosy control. It also focuses on reducing stigma and promoting inclusiveness for better and earlier diagnosis of leprosy. Innovative approaches for children, women and other vulnerable populations like strengthening referral systems, systematic tracing of household contacts, monitoring drug resistance, simplified treatment approach and assessing the role of post exposure prophylaxis are emphazised¹. The principles of global strategy are developing country-specific plans, ensuring accountability by strengthening monitoring in all endemic countries and promoting inclusion by establishing and strengthening partnerships with all subjects or communities affected by leprosy. The fundamental of strategy of Sustainable Development Goal 3 aims at reaching health and wellbeing for all by 2030. It also aims to reduce the burden of leprosy at the global and the local level by strengthening government ownership, coordination and partnership, stopping leprosy, its complications, discrimination and promoting inclusion.^[1]

One of the key strategic operational changes focuses on early case detection before visible disabilities occur.^[2] The main strategy to further reduce the global and local leprosy by 2020 are Zero G2D among paediatric leprosy patients, reducing the number of new leprosy cases with G2D to less than one case per million population and Zero countries with legislation that allows discrimination on basis of leprosy.^[3] It also aims at target detection among higher risk groups by conducting campaigns in highly endemic areas or communities thereby improving coverage and access for marginalized sectors. This will result in earlier detection and reduction of patients with grade-2 disabilities (G2D) at the time of diagnosis and to bring the target of G2D rate is less than one per million population. Since 1995-2010, there has been a gradual reduction of G2D every 5 years in the leprosy endemic countries and especially in India by 53.7%.^[4] In this scenario, this observational study was conducted in leprosy OPD of a tertiary care centre in south India between Jan’ 2018 and Dec’ 2018 to study the frequency and severity of grade 1 and grade 2 deformity among leprosy cases with emphasis on newly diagnosed leprosy patients along with clinical and socioeconomical factors.

Materials and Methods

This prospective observational study included 212 cases that attended the Hansens OPD during the study period. They were assessed based on clinical, socio-economical factors and WHO disability grading. Among them the total cases of deformity was 62 and those with newly diagnosed cases were 5. The protocol of the study was approved by the Institutional ethical committee before commencing the study. Informed written consent was obtained from all the patients before inclusion into the study. The details of clinical and sociodemographic factors from the cases attending Hansen OPD, Govt. Thiruvarur Medical College, were collected and analyzed. The district Thiruvarur, located in southern India has a leprosy prevalence rate of 0.70 for the year 2017. The corresponding prevalence rate of Tamil Nadu for 2017 was 0.41 and when compared to our country was 0.66.^[3]

All diagnosed leprosy patients with deformities who presented at the Hansen OPD were included. The Inclusion criteria for the study was all diagnosed leprosy patients with deformities attending Hansen OPD and exclusion criteria were Deformities due to other causes and subjects not willing for inclusion in the present study period. The enrolled cases were advised to come for review after 1 to 2 weeks according to the investigations taken and at regular interval periods during treatment. A detailed history, socio-demographic data and clinical examination was carried out and all subjects according to NLEP manual.^[5] All the cases were subjected to routine blood investigations and slit skin smear examination. Suspicious cases of leprosy were confirmed by skin biopsy. Nerve conduction studies, neurological evaluation for thickened nerve and sensory and motor nerve function impairment were done to suspected cases of pure neuritic leprosy cases.^[6] WHO - 3 point disability scale classification was used to grade the eyes, hand and foot deformities.^[7] Sensory testing for the hands was done in six sites in each palmar aspect and for each foot in four sites.^[8] Sensory nerve function impairment was noted by testing the subjects inability to identify the sensory stimulus under 2 cms and was considered a positive result when 2 or more areas did not have sensation.^[9]

 By assessing the Voluntary muscle testing, positive Motor nerve function impairment was noted as weak and paralysed.^[5] Assessment of motor nerve function impairment of both hands against resistance was done by abduction movement thumb, index and little fingers, opposition movement of the thumb and wrist extension movement. Assessment of motor nerve function impairment of both foot against resistance was done by eversion and dorsiflexion of the foot and hallux extension. Impairments that are visible like ulcers, fissures, absorption, clawing, contractures of fingers and toes along with wrist drop and foot drop were noted as Grade 2 deformity. Grade 1 disability of the eye was assessed by noting the corneal sensation loss by using cotton wisp.^[7] Motor nerve function impairment assessment of the eyes was noted by the subjects ability to close the eyes with resistance. Impairments of the eye like madarosis, lagophthalmos, conjunctivitis, iridocyclitis and corneal opacities was recorded as grade 2 disability. Xray, orthopaedic and ophthalmological evaluation (for assessing visual acuity using Snellen’s chart)^[7] were done in selected deformity cases. The reports of all the investigations and opinion were collected and recorded. Data collected were entered and analysed according to the WHO grading of disability and deformity index and compiled in percentages, chi-square and ANOVA method.

Results

On analysis of data from 212 leprosy subjects collected, 62 cases had deformities and disability and the deformity index was 29.2%. Among them newly diagnosed leprosy cases that showed grade 1 disability was two and grade 2 disability was three. Of these 62 cases, 43(69.4%) were male sex and 19(30.6%) were female sex. Hence deformities were more commonly seen in male sex (P = 0.045) compared to female sex with a male:female ratio of 7:3. The age group most commonly affected was 41-50 years with 19 (30.6%) subjects, followed by 20-30 years age group with 14(22.6%) cases.Hence deformities were seen most commonly in the age group of 41-50 years. (P = 0.128) Significant numbers of deformities were noted in lower socioeconomic class 26(41.9%) cases when compared to upper socioeconomic class 17(27.4%) cases. Subjects who do manual work like farmers, construction workers, 43 (70.1%) cases had significant disability (P <0>5 years 18(29%) cases. Deformities were lowest in 0-2 years duration group 15(24%) cases. (Table 1)

Deformities were commonly seen in lepromatous leprosy spectrum of the disease with 20(32%) cases followed by borderline lepromatous spectrum with 17(28%). (Table 2) Subjects with greater than 5 skin lesions 17(27.41%) cases had lesser disability than subjects with less than or equal to 5 skin lesion 33(53.22%) cases and this data was statistically significant (P <0>P<0>

 Deformities were more common in the hands 48(77.42%) cases [Fig. 1-2] followed by both hand and feet 41(66.13%). It was further followed by feet 25(40.32%) cases [Fig. 3], face 7(11.29%) cases[Fig. 4], eyes 5(8.06%) cases and ears 5 (8.06%) cases.[Fig. 5](Table 5) In subjects with hand deformities, sensory loss (sensory NFI) was found to be more common 25(40.32%) cases followed by numbness 14(22.58%) cases and weakness of hands(motor NFI) in 11(17.74%) subjects respectively. (Table 6). In case of foot deformities, numbness (paraesthesia) was found to be common with a total of 14(22.58%) cases followed by glove and stocking type of anesthesia in 12 (19.35%) cases, sensory loss (sensory NFI) in 9(14.52%) cases and last by weakness (motor NFI) in 3(4.84%) cases. (Table 7) Grade 2 deformities were seen more commonly in the feet 36 (58.06%)cases when compared to the hands 26(41.94%) cases. Anaesthetic type of deformity was more commonly noted in 51(82.26%) subjects to be followed by specific deformities in 22(35.48%) subjects and paralytic deformity in 20(32.25%) subjects. Specific complications arising due to involvement of hand and foot deformities noted in our study was mycetoma occurring in the hand and foot. [Fig. 6] This may be due to the farming occupation sector that is more common in the delta districts of south India. In the eyes, corneal sensory loss [Grade 1] was seen in 3.2% of

cases followed by lagophthalmos and severe impairment of

visual acuity (vision < 6>

Table 1:Duration of the disease in patients with deformities