Leprosy cases are rising in the US – what is the ancient disease and why is it spreading now?

leprosy

By Robert A. Schwartz, Rutgers University

The word “leprosy” conjures images of biblical plagues, but the disease is still with us today. Caused by infectious bacteria, some 200,000 new cases are reported each year, according to the World Health Organization. In the United States, leprosy has been entrenched for more than a century in parts of the South where people came into contact with armadillos, the principle proven linkage from animal to humans. However, the more recent outbreaks in the Southeast, especially Florida, have not been associated with animal exposure.

The Conversation talked with Robert A. Schwartz, professor and head of dermatology at Rutgers New Jersey Medical School, to explain what researchers know about the disease.

What is leprosy and why is it resurfacing in the US?

Leprosy is caused by two different but similar bacteria — Mycobacterium leprae and Mycobacterium lepromatosis — the latter having just been identified in 2008. Leprosy, also known as Hansen’s disease, is avoidable. Transmission among the most vulnerable in society, including migrant and impoverished populations, remains a pressing issue.

This age-old neglected tropical disease, which is still present in more than 120 countries, is now a growing challenge in parts of North America.

Leprosy is beginning to occur regularly within parts of the southeastern United States. Most recently, Florida has seen a heightened incidence of leprosy, accounting for many of the newly diagnosed cases in the U.S.

The surge in new cases in central Florida highlights the urgent need for health care providers to report them immediately. Contact tracing is critical to identifying sources and reducing transmission.

Traditional risk factors include zoonotic exposure and having recently lived in leprosy-endemic countries. Brazil, India and Indonesia have each noted more than 10,000 new cases since 2019, according to the World Health Organization data, and more than a dozen countries have reported between 1,000 to 10,000 new cases over the same time period.

Why was leprosy stigmatized in biblical times?

Evidence suggests that leprosy has plagued civilization since at least the second millennium B.C.

From that time until the mid-20th century, limited treatments were available, so the bacteria could infiltrate the body and cause prominent physical deformities such as disfigured hands and feet. Advanced cases of leprosy cause facial features resembling that of a lion in humans.

Many mutilating and distressing skin disorders such as skin cancers and deep fungal infections were also confused with leprosy by the general public.

Fear of contagion has led to tremendous stigmatization and social exclusion. It was such a serious concern that the Kingdom of Jerusalem had a specialized hospital to care for those suffering from leprosy.

How infectious is leprosy?

Research shows that prolonged in-person contact via respiratory droplets is the primary mode of transmission, rather than through normal, everyday contact such as embracing, shaking hands or sitting near a person with leprosy. People with leprosy generally do not transmit the disease once they begin treatment.

Armadillos represent the only known zoonotic reservoir of leprosy-causing bacteria that threaten humans. These small mammals are common in Central and South America and in parts of Texas, Louisiana, Missouri and other states, where they are sometimes kept as pets or farmed as meat. Eating armadillo meat is not a clear cause of leprosy, but capturing and raising armadillos, along with preparing its meat, are risk factors.

The transmission mechanism between zoonotic reservoirs and susceptible individuals is unknown, but it is strongly suspected that direct contact with an infected armadillo poses a significant risk of developing leprosy. However, many cases reported in the U.S. have demonstrated an absence of either zoonotic exposure or person-to-person transmission outside of North America, suggesting that transmission may be happening where the infected person lives. But in many cases, the source remains an enigma.

Some people’s genetics might make them more susceptible to leprosy infections, or their immune systems are less capable of resisting the disease.

Stigma and discrimination have prevented people from seeking treatment, and as a result, “concealed” cases contribute to transmission.

How do you recognize it?

Leprosy primarily affects the skin and peripheral nervous system, causing physical deformity and desensitizing one’s ability to feel pain on affected skin.

It may begin with loss of sensation on whitish patches of skin or reddened skin. As the bacteria spread in the skin, they can cause the skin to thicken with or without nodules. If this occurs on a person’s face, it may rarely produce a smooth, attractive-appearing facial contour known as lepra bonita, or “pretty leprosy.” The disease can progress to causing eyebrow loss, enlarged nerves in the neck, nasal deformities and nerve damage.

The onset of symptoms can sometimes take as long as 20 years because the infectious bacteria have a lengthy incubation period and proliferate slowly in the human body. So presumably many people are infected long before they know that they are.

Fortunately, worldwide efforts to screen for leprosy are being enhanced thanks to organizations like the Order of Saint Lazarus, which was originally founded in the 11th century to combat leprosy, and the Armauer Hansen Research Institute, which conducts immunologic, epidemiological and translational research in Ethiopia. The nongovernmental organization Bombay Leprosy Project in India does the same.

How treatable is it?

Leprosy is not only preventable but treatable. Defying stigma and advancing early diagnosis via proactive measures are critical to the mission of controlling and eradicating it worldwide.

Notably, the World Health Organization and other agencies provide multi-drug therapy at no cost to patients.

In addition, vaccine technology to combat leprosy is in the clinical trials stage and could become available in coming years. In studies involving nine-banded armadillos, this protein-based vaccine delayed or diminished leprous nerve damage and kept bacteria at bay. Researchers believe that the vaccine can be produced in a low-cost, highly efficient manner, with the long-term prospect of eradicating leprosy.

If health care professionals, biomedical researchers and lawmakers do not markedly enhance their efforts to eliminate leprosy worldwide, the disease will continue to spread and could become a far more serious problem in areas that have been largely free of leprosy for decades.

The World Health Organization launched a plan in 2021 for achieving zero leprosy.The Conversation

Robert A. Schwartz, Professor and Head of Dermatology, Rutgers New Jersey Medical School, Rutgers University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Clinical Notes : Diabetes, medical honey, silver dressings, clostridium

Guidelines for optimal off-loading to prevent diabetic foot ulcers 

The management of diabetic foot ulcers through optimal off-loading,” published in the Journal of the American Podiatric Medical Association, presents consensus guidelines and states the “evidence is clear” that off-loading increases healing of diabetic foot ulcers.

The article calls for increased use of off-loading and notes that “current evidence favors the use of nonremovable casts or fixed ankle walking braces as optimum off-loading modalities.” The authors reviewed about 90 studies. (more…)

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Successful documentation of wound care

By Cheryl Ericson, MS, RN, CCDS, CDIP

Providers are often surprised at how pages upon pages of documentation in a patient’s health record can result in few reportable diagnosis and/or procedure codes, which often fail to capture the complexity of the patient’s condition. However, providers need to be aware of the implications of coding. As healthcare data become increasingly digital through initiatives such as meaningful use, coded data not only impact reimbursement but also are increasingly used to represent the quality of care provided. Here’s a closer look at how documentation and coding work in the context of wound care. (more…)

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Fifty shades of wound care at home

By Beth Hoffmire Heideman, MSN, BSN, RN, WCC, DWC, OMS

Fifty shades of wound care at home refers to treating the whole patient and the patient’s caregiving supporters—not just the wound. Only by understanding the nuances, or shades, of a patient and his or her environment can clinicians best achieve desired outcomes.

Wound healing in home care depends on teamwork. Members of the team must understand the unique situation of delivering care in the home and how to help patients adhere to the plan of care. (more…)

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Improving outcomes with noncontact low-frequency ultrasound

By Ronnel Alumia, BSN, RN, WCC, CWCN, OMS

Achieving excellent wound care outcomes can be challenging, given the growing number of high-risk patients admitted to healthcare facilities today. Many of these patients have comorbidities, such as obesity, diabetes, renal disease, smoking, chronic obstructive pulmonary disease, and poor nutritional status. These conditions reduce wound-healing ability. (more…)

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Clinician Resources

There’s an app for that! Here are a variety of medical apps that you might want to try. You can download them in the iTunes store, and the basic service is free.

Medscape

More than 1.4 million healthcare professionals use this app from WebMD, which includes:
• medical news
• clinical reference information, such as drugs and diseases
• medical calculators (not available for iPad).
The app is available for Android, iPad, and iPhone/iPod touch devices.

http://medscape.com

Pressure Wound Analyzer

Use this app to take a photo of a wound. The app segments the image into red, yellow, and black to help with ulcer classification. You can also use the app to track changes in the wound over time. The app is available for iPad and iPhone/iPod touch devices. Note: This is free for a limited time.

http://woundanalyzer.blogspot.com

AHRQ ePSS

The ePSS (Electronic Preventive Services Selector) app allows you to search and browse the U.S. Preventive Services Task Force recommendations on the Web or a mobile device. The app is from the U.S. Department of Health & Human Services and is available for Android, iPad, and iPhone/iPod touch devices.

http://epss.ahrq.gov

UMSkinCheck

This app from the University of Michigan Health System allows users to complete and store photographs of the skin. Features include:
• guidance on performing a skin cancer self-exam and full-body photographic survey
• tracking of detected skin lesions and moles for changes over time
• notifications/reminders to perform self-exams on a routine basis
• storage of photos for baseline comparisons during routine follow-up self-
exams
• informational videos and literature on skin cancer prevention and healthy skin as well as a skin cancer risk calculator function.
The app is available for iPad and iPhone/iPod touch devices.

http://uofmhealth.org/patient%20and%20visitor%20guide/my-skin-check-app

Glucose Buddy—Diabetes Logbook Manager w/syncing, blood pressure, weight tracking

This data storage utility app is perfect for your patients with diabetes who want all their information in one place. Users can manually enter their glucose results, carbohydrate consumption, insulin dosages, and activities, and then view the data in a free glucosebuddy.com online account. Another option is the ability to set reminders for when it’s time to check blood glucose.
The app is available for Android, iPad, and iPhone/iPod touch devices.

http://www.glucosebuddy.com

3M Health Care Pressure Ulcer Staging

Use this app to learn more about pressure ulcer staging. It includes information about 3M pressure ulcer products.
The app is available for iPad and iPhone/iPod touch devices.

https://itunes.apple.com/us/app/3m-health-care-pressure-ulcer/id454537520?mt=8

SACS™ Instrument

This evidence-based tool is helpful for assessing and classifying peristomal skin lesions. Click here for more information about the SACS Instrument.
The app is available for iPad and iPhone/iPod touch devices.

http://www.convatec.com/en/cvtus-homeus/cvt-home/0/home/0/393/0/default.html?
hwcr=flex

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Why not call it a pressure ulcer?

By: Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

The most basic principle of healing a wound is to determine the cause—and then remove it. This is easier said than done, as many wounds have similar characteristics and we don’t always know all the facts leading up to the wound.
The process has been unnecessarily complicated by the recent pressure (no pun intended) to avoid at all costs calling a pressure ulcer a pressure ulcer. I use the term “unnecessarily” because it doesn’t matter what it’s called—a pressure ulcer, decubitus, “de-cube,” or bedsore—because in the end, the general idea is it’s bad news.
So what’s behind the desire to avoid calling it a pressure ulcer? First, a pressure ulcer has traditionally been equated to poor nursing care. As Florence Night­in­gale, the “Mother of Nursing,” wrote:
If he has a bedsore, it’s generally not the fault of the disease, but of the nursing.”
No one likes to feel that he or she gave poor care, and as more hospital complications data are available to the public, reports of complications such as pressure ulcers affect people’s perceptions—right or wrong—about the care a hospital delivers.
The second reason gets at the “at all costs” part of the desire. The recent attention given to Medicare’s “present on admission” rule and “never” events has
elevated pressure ulcers high up the chain of “no-no’s” and put the hospital at risk for nonreimbursement. And many private insurers have followed Medicare’s lead in denying coverage for pressure ulcers that occur in the hospital. Unfortunately, all the focus on reimbursement is beginning to challenge even the best wound care experts, who simply want to get the patient’s wound healed.
Pressure from upper management has resulted in experts trying to bargain and rationalize their way out of calling it what it is (a pressure ulcer), instead calling it a bruise, not a deep-tissue injury. Or saying, “This is a shearing ulcer, not a pressure ulcer.” Or, my favorite: “It’s not an ischial pressure ulcer but a diabetic ulcer because the patient is a diabetic.” Wound care experts are being forced to question and doubt themselves because money, quality assurance, and reputation are on the line when an in-house wound is labeled a pressure ulcer.
Like crime scene investigation, determining wound etiology requires us to gather all the facts. Once the facts are in, systematically comparing and contrasting the clinical findings aids differential identification to pin down the type of wound present. It’s important that we assess and investigate all the following when searching for the cause:
•    patient’s medical history
•    recent activities (such as surgery, extensive X-rays, or long emergency-
department waits)
•    comorbidities
•    specific wound characteristics, such as location, distribution, shape, wound bed, and surrounding skin.

Naming the wound is an important first step in intervening. If the wound is caused by pressure, call it a pressure ulcer and jump into action. Remove the cause, heal the wound, and prevent further breakdown. Don’t let yourself be influenced by those who aren’t experts in wound care.

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Editor-in-Chief
Wound Care Advisor
Cofounder, Wound Care Education Institute
Plainfield, Illinois

Selected reference
Nightingale F. Notes on Nursing: What It Is, And What It Is Not. London: Harrison and Sons; 1859. http://ia600204.us.archive.org/17/items/notes
nursingnigh00nigh/notesnursingnigh00nigh.pdf.

Accessed August 30, 2012.

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