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Leprosy Leprosy has struck fear into human beings for thousands of years, and was well recognized in the oldest civilizations of China, Egypt, and in India. A cumulative total of the number of individuals, who over the millennia have suffered its chronic course of incurable disfigurement and physical disabilities, can never be calculated. Since ancient times, the community has regarded leprosy as a contagious, mutilating, and incurable disease. Yet, despite the advances of modern technology, many people continue to hold old and outdated belief's about leprosy, which continues to the stigma attached to the disease. "Leprosy is a chronic infectious disease caused by Mycobacterium laprae, an acid-fast, rod-shaped bacillus, related to the tuberculosis bacillus." The disease mainly effects the muccous membranes of the upper respiratory tract, the peripheral nerves, the skin and the eyes. The infection is very slow to develop, ranging from six months to ten years. There are many countries in Asia, Africa and Latin America with a significant number of leprosy cases. "As of 1997 around 2,100,000,000 people live in countries where prevalence of leprosy is more that one case per 10,000 population." It is estimated that there are between one and two million people visibly and irreversibly disabled due to past and present leprosy who require to be cured for by the community in which the live. When G.A. Hansen in1873 discovered M. Leprae, it was first bacterium to be identified as causing disease in man. "However, treatment for leprosy only appeared in the late 1940s with the introduction of dapsone and it's derivatives." Leprosy bacilli resistant to dapsone gradually appeared and because widespread. "In 1997, there were an estimated 1.2 million cases in the world, most of them concentrated in South-East Asia, Africa and the Americas. The number of new cases detected worldwide each year is about half a million." Diagnosis of leprosy is most commonly based in the clinical signs and symptoms. These are easily to observe and elicit by any health worker after a short period of training. In practice, most often persons with such complaints report on their own to the health center. Only in rare instances is there a need to use laboratory and other investigations to confirm a diagnosis of leprosy. In an endemic country or area, an individual should be regarded as having leprosy if he or she shows one of the following cardinal signs: 1-skin lesions consistent with leprosy and with definite sensory loss; with or without thickened nerves. The skin lesion can be single or multiple, usually less pigmented than the surrounding normal skin. Sometimes the lesion is pigmented reddish or copper-colored. A variety of skin lesions may be seen but macules (flat) papules (raised), or nodules are common. Sensory loss is a typical feature of leprosy. A thickened loss is typical feature of leprosy. Other signs often accomplish a thickened nerve as a result to the nerve. These may be loss of sensation in the skin and weakness of muscle supplies by the affected nerve. In the absence of these signs, nerve thickening by itself, without sensory loss and or muscle weakness is often not a reliable sign of leprosy. 2- Positive skin smears: In a small proportion of cases, rod-shaped, red-stained leprosy bacilli, which are diagnostic of the disease, may be seen in the smears taken from the affected skin when examined under a microscope after a appropriate staining. A person presenting with skin lesions or with symptoms suggestive of nerve damage, in which the cardinal signs are absent or doubtful, should be called a 'suspect case' in the absence of any immediately obvious alternate diagnosis. "Such individuals should be told the basic facts of leprosy and advised to return to center if signs persist for more than six months or if at anytime worsening is noticed." "Suspect cases may also be sent to referral clinics with more facilities for diagnosis." There are two main types of reactions to M. leprae in the body. Tuberculoid leprosy, the milden form, causes the bodies cells to crowd around the invading organisms in the deep skin layers, which are the first areas of infection to be destroyed. The skin becomes dry and discolored and loses it sense of touch. Fingers and toes that have no feeling are easily injured, and if, the patient doesn't take special care to protect them, they may in time become mutilated and fall off. Lepromatous leprosy, the second and more contagious form of the disease, the body is unable to mount a resistance, and the M. leprae multiply freely in the skin. Large, soft, bumps appear over the body and face. Mocous membranes of the eyes, nose and throat may be invaded. In extreme cases the voice may change drastically, blindness may occur, or the nose may be destroyed. Leprosy is not a highly communicable disease. "Only about five percent of family members living with leprosy patients develop the disease." From this observation and other accumulated epidemiological data, it's widely believed that more than ninety percent of adults in most populations are resistant to leprosy. The mode of transmission remains unclear. Transmission may take place by skin contact or the bacilli may enter through the mocous membranes of the mouth, nose, or through abrasions in the skin. "Natural transmission by insects was previously thought to have no role but recent studies have shown that insects do have part in the transmission." Bed bugs and mosquitoes in areas of leprodaria commonly harbor M. leprae, and the disease can be transmitted to mice by infected mosquitoes. Currently mounting evidence from several sources suggests that leprosy may be transmitted through soil and the disease is primarily rural, not urban. Leprosy is curable, but the nerve damage and deformities are irreversible. If the disease is caught early enough, however, the patient can be completely cured. Treatment of the disease has evolved from only using the drug dapsone to the widespread use of multi-drug therapy, which includes dapsone, rifampicin, and clofazine. These are all strong antibacterial drugs. The change from a single drug to multiple drugs came about because a serious problem with secondary dapsone resistance caused by a variety of reasons including the many patients' inability to take drugs daily. "Since the introduction of multi-drug therapy in 1971 in the United States, the resistance by the disease to drugs has discontinued." Treatment can range from six months to five years depending on the type of leprosy. The disease is not highly communicable and is slow to develop. Most people are even resistant to the disease. Leprosy is a very curable with long-term treatment regimen of various drugs. Nevertheless, many misconceptions are passed on, even in the United States, where it is not a problem. The drugs used in WHO-MDT are a combination of rifampicin, clofazimine and dapsone for MB leprosy patients. Among these rifampicin is the most important antileprosy drug and therefore is included in the treatment of both types of leprosy. Treatment of leprosy with only one antileprosy drug will always result in development of drug resistance to that drug. "Treatment with dapsone or any other anti-leprosy drug used as monotherapy should be considered as unethical practice." Rifapicin: The drug is given once a month no toxic affects have been reported in the case of monthly administration. The urine may be colored slightly reddish for a few hours after its intake; this should be explained to the patient while starting MDT. Clofazimine: IT is most active when administered daily. The drug is well tolerated and virtually nontoxic in the dosage used for MDT. "The drug causes brownish black discoloration and dryness for skin. However, this disappears within few months after stopping treatment. This should be explained to patients starting MDT regimen for MB leprosy." Dapsone: The drug is very safe in the dosage used in MTD and side effects are rare. The main side effect is allergic reaction, causing itchy skin rashes and explosive dermatitis. Patients known to be allergic to any of the suepha drugs should not be given dapsone. "The standard regimens of multibacilliary leprosy for an adult is: Rifamipicin: 600mg once a month. Dapsone: 100mg daily. Clofazimine: 300mg once a month and 50mg daily. Duration: twelve months. The standard regimens of paucibacillary leprosy is: Rifaminpicin: 600mg once a month Dapsone: 100mg daily Duration: six months." Leprosy is often called the "living death" because of the many horrifying effects on the human body. Without the cure, it can leave people deformed and hopeless for the rest of their lives. Leprosy also robs its victims of their eyesight. When leprosy affects facial nerves, a person loses the blinking reflex of the eye, which eventually leads to dryness, ulceration, and blindness. The cornea can also become numb, so the person doesn't know when dirt or particles cause irritation. Leprosy also deforms its victims' faces. Leprosy bacilli can enter the mucous lining of the nose, leading to internal damage and scaring. Eventually the damage causes the nose to collapse. Leprosy mutilates its victims' hands. When the ulnar nerve above the elbow is affected by leprosy, part of the hand becomes numb and small. Muscles become paralyzed, leading to a curling of the fingers and without treatment, more severe damage. "Leprosy bacilli attack peripheral nerves, leading to a loss of feeling." "Patients lose the automatic withdraw reflexes which protect against hot or sharp objects. Burns and other wounds become infected and tissues and bones are eventually eroded." Leprosy destroys the victims' feet. When leprosy attacks the nerves in the legs, it interrupts the communication of sensation in the feet. The feet then become subject to bone damage and deformity though unnoticed wound and infection. Serious infections can lead to amputations. There is a lot of history of leprosy in the United States. Although leprosy is not predominately a United States problem, the history of the disease here is worth nothing. Leprosy was introduces to the United States at several specific locations and from the many immigrants centering the country starting in the 1700s. Although the disease has been reported in most states at one time or another, there have been seven centers of infection present in the country. The centers are Louisiana, Texas, Florida, California, Hawaii, and New York, which account for an overwhelming majority (80.5%) of all leprosy cases reported in the United States and the Mississippi River Valley which is no longer a major center of infection. "One of the earliest centers of leprosy infection develop was in French Louisiana. Although leprosy is believed to have been present in Louisiana prior to 1775, the arrival of the Acadian population from Canada beginning that year appears to have added substantially to the infected population." Affected by immigration from all parts of Louisiana, New Orleans has experienced an increase in its relative incidence rate during the past twenty years. The highest incidence rates among blacks in Louisiana occur in the French parishes and not in the traditional slave-holding regions. "This fact lends acceptance to the argument that no evidence has been forthcoming which would link the importation of slaves to the United States to an increase in the rate of leprosy." Nonetheless, Louisiana has remained one of the truly endemic areas of infection in the United States with 76% of its cases occurring in persons in that state. Texas also has a significant population of leprosy sufferers, with the population predominately of Spanish decent. Four major areas of infection have been identified within the state. The first is in the south centered in the Rio Grande Valley. The second major focus is in the Corpus Christi area. San Antonio is the third concentration and the fourth and largest center of infection is in the southeastern part of the state near the Louisiana border and is centered in the Houston-Galveston complex. "Contributing to over 33% of the states cases, the concentration is apparently the result of the contact with the French Louisiana in that the majority of the cases are found in people with non-Spanish surnames." Texas is the only other state besides Louisiana in which most of the leprosy cases occurring in the state are found in the native-born state population. Texas also contains over one half of all native-born cases in the United States. Over the past several decades the major concentration of leprosy in Florida has shifted from Key West to Miami. In all likelihood this is due to Miami superseding Key West as a port of entry to the United States. Leprosy was initially brought to Florida from the West Indies and the Caribbean, and this area remains the principle source region of the 86% of Florida's cases that are foreign born. "Within the last two decades the Cuban population has contributed substantially to the number of leprosy cases reported in the United States." Most of these Cubans are found in Florida, with the majority in Miami. Currently a controversy exists over the admittance of Cuban refuges and Cuban immigrants who may have either leprosy or has been contacted with a sufferer in Cuba. Since the middle of the last century, California has experienced a relatively high incidence of leprosy. Its first cases were imported from both Mexico and China. Later, cases began to arrive from other parts of the world, most notably the Philippines. Today over 90% of California's cases are found in foreign born patients, with Mexican and Filipino populations accounting for the majority of these cases. "Most of the leprosy present in California is found in the large population centers, particularly San Francisco, Los Angeles, and San Diego. Currently, California is the largest contributor to the total leprosy population in the United States." The Hawaiian Island's appear to have had a long history of leprosy, as there was a substantial infected population in existence in the mid-nineteenth century. As the percentage of Hawaii's foreign-born population has increased so has the percentage of foreign born cases of leprosy. "Currently representing over 80% of the state's total of reported cases. The Filipino population accounts for the largest portion of these imported cases." "The Philippines in general have contributed substantially to the number of leprosy sufferers in the United States, accounting for over one-fith of all cases reported since 1967." Historically, New York City has been the major port of entry to the United States for most of the country's immigrant population. Nearly all cases reported in that area were found in patients that were born outside of the U.S. The primary source area for these cases is in the Caribbean, with Puerto Rico accounting for an overwhelming majority of all cases reported in New York. The increase in leprosy incidence since 1942 has been slight and erratic. Today it is estimated that there are approximately 4,000 leprosy cases in the United States. During the Middle Ages lepers were separated from the rest of the population by a requirement of church law. According to Levitical law, the leper was considered dead to the world, without rights to marriage or property, and required to live apart. A decree of the Lateran Council in 1179 required lepers to be buried in separate graveyards. Diagnosis in mediaeval times began with whether the person is leprous or whether they need to remain under observation. In order to become free of dreaded disease, the patient had to get a medical certificate of freedom from the disease, according to best medieval practice. "A study in the Philippines of the Tausug, an indigenous tribe, showed that the stigmentation of the people with leprosy is manifestations behaviorally and psychologically. The behavioral manifestations were shown by acts of isolation and ostracism. For instance, it is not uncommon for a person with leprosy to not be allowed on public transportation. The authors determined the psychological stigmatization by an analysis of language structures used by the interviewees. The analysis showed perceptions, the emotional state the informant is in, and convey overt messages." Certain customs and folk beliefs also contribute to the attitude of the Tausug towards leprosy. They believe that the disease is highly contagious and that the disease came from the "Northern part of Jolo"-some distant place. Many believe that the disease originated from a curse or punishment from the Almighty. The Tausug burn the corpses and belongings of the people with leprosy. According to that study, the Tausug looked at the disease as a, "dirty sickness", and consistently described it using the word meaning "to corrode, disintegrate, eaten into, gnawed, or wear away gradually". The Tausug believe a minute insect-like organism that centers the bloodstream and causes the ill effects of leprosy. They believe leprosy is highly transmittable because the Kagawa can travel easily from one host to another. Conversing or shaking hands, shopping at the same stores, bathing in the same area with a person who has leprosy is believed to expose one to the disease. In India leprosy is called the "illness of untouchability", because it stigmatizes people in such a way that they become essentially untouchable. "For example, a diagnosis of leprosy is grounds for divorce in India. In addition, people with the disease may be barred from public transportation unless they carry proof that they are receiving treatment that has rendered them not contagious." India has the greatest number of cases, about one million presently, which may continue significantly to the problem of stigma. With such a large part of the population affected, the fear of contracting the disease may be greater. In Southern Nigeria, the native name for leprosy is Opo-and is seldom used fear that the repetition could cause the sickness to come upon the speaker. The supernatural agencies, heredity or by poisons. In most cases the leper is isolated when recognized, but if the family is wealthy the attempt is resisted and money is spent in making the disease non-dangerous. When isolation is complete, a hut is built far from the town, and the leper isn't allowed to leave until the morning has passed. It's an evil thing to see the leper in the morning; it's necessary to undergo some ceremonial cleansing and sacrifice so the sickness will not result. The disease is so feared that people are always on the watch. In some towns, elders make periodical inspections of all the inhabitants. When a man goes to see the parents of the prospective bride, he goes in a native dress, a loin cloth. Until he is married he assists in the farm of his bride's parents during which time the couple have an opportunity to assure themselves that they are both free from infection. No man will wrestle an opponent that is fully clothed. Anyone who is fully clothed is under suspicion, and at village feasts, native costume is the official dress. The death of the leper is a sordid end to a miserable existence. In many places murder was the only effective prophylactic known. Generally the leper isn't allowed to die in the town, if it can be avoided. Just before the end, men hired for the occasion and fortified with an antidote, escort the sufferer to the "bad brush", and watch to make sure that the leper doesn't return. In other cases, the grave is prepared just outside the house and the leper is pushed inside while still alive. Immediately death takes place, the grave is closed, the house broken up, and a fire lit over the grave to destroy the sickness as it leaves the body to enter someone else. "Currently there are about 1.8 million cases of leprosy in the world, with about five hundred thousand new cases each year. Of those, approximately one hundred thousand of those cases are children." "Approximately four thousand of those patients with leprosy live in the United States, with about two hundred and fifty to three hundred new cases reported each year. According to Frank Parker, MD, the new cases are not contracted in the United States, but appear in people who have spent time in foreign countries, especially in the South Pacific. Between two and three million people have deformities due to leprosy. The disease today is most prevalent in tropical countries, although the climate has little to do with its spread. Five countries-Brazil, India, Indonesia, Myanmar and Nigeria, accounting for eighty

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