Leprosy Today

Child with leprosy

Today, the diagnosis and treatment of leprosy is easy and most endemic countries are striving to fully
integrate leprosy services into existing general health services.
This is especially important for those under-served and marginalised communities most at risk from
leprosy, often the poorest of the poor.

Access to information, diagnosis and treatment with multidrug therapy (MDT) remain key elements in the
strategy to eliminate the disease as a public health problem, defined as reaching a prevalence of less than
1 leprosy case per 10,000 population. MDT treatment has been made available by WHO free of charge to
all patients worldwide since 1995, and provides a simple yet highly effective cure for all types of leprosy.

According to official reports received during 2010 from 141 countries and territories, the global registered
prevalence of leprosy at the beginning of 2010 stood at 211,903 cases, while the number of new cases
detected during 2009 was 244,796 (excluding the small number of cases in Europe).

Most previously highly endemic countries have now reached elimination (defined as a registered
prevalence rate of <1 case/10 000 population). During 2007, both the Democratic Republic of the Congo
and Mozambique reached this important stage. Those few countries that remain are very close to
eliminating the disease. However, pockets of high endemicity still remain in some areas of Angola,
Brazil, Central African Republic, Democratic Republic of Congo, India, Madagascar, Mozambique,
Nepal, and the United Republic of Tanzania. These countries remain highly committed to eliminating the
disease, and continue to intensify their leprosy control activities.

Information campaigns about leprosy in high risk areas are crucial so that patients and their families, who
were historically ostracized from their communities, are encouraged to come forward and receive
treatment. The most effective way of preventing disabilities in leprosy, as well as preventing further
transmission of the disease, lies in early diagnosis and treatment with MDT.
 Leprosy
Leprosy is caused by a slow-growing bacillus, Mycobacterium leprae. It is
transmitted via droplets from the nose and mouth of untreated patients with severe
disease, but is not highly infectious. If left untreated, the disease can cause nerve
damage, leading to muscle weakness and atrophy, and permanent disabilities.
Leprosy can be easily treated with a 6–12-month course of multidrug therapy. The
treatment is highly effective, and has few side-effects and low relapse rates; there
is no known drug resistance.
Information campaigns about leprosy in high risk areas are crucial so that patients
and their families, who were historically ostracized from their communities, are
encouraged to come forward and receive treatment. The most effective way of
preventing disabilities in leprosy, as well as preventing further transmission of the
disease, lies in early diagnosis and treatment with MDT.

Leprosy statistics - latest data

Every year WHO receives official data on leprosy from more than 120 national programmes in Member
States worldwide. However, this data generally only becomes available in July of each year, and reflects
the situation during and at the end of the preceding year.
As the latest individual country data becomes available it will be posted on this page. Rates of prevalence
and new case detection are for 1 case per 10,000 and per 100,000 population, respectively.

Leprosy: the disease

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, an acid-fast, rod-shaped

bacillus. The disease mainly affects the skin, the peripheral nerves, mucosa of the upper respiratory tract
and also the eyes, apart from some other structures. Leprosy has afflicted humanity since time
immemorial. It once affected every continent and it has left behind a terrifying image in history and
human memory - of mutilation, rejection and exclusion from society.
Leprosy has struck fear into human beings for thousands of years, and was well recognized in the oldest
civilizations of China, Egypt and 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, leprosy has been regarded by the community as a contagious, mutilating and
incurable disease. There are many countries in Asia, Africa and Latin America with a significant number
of leprosy cases. 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 cared for by the community in which they live.
When M.leprae was discovered by G.A. Hansen in 1873, it was the 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 its derivatives. Leprosy bacilli resistant to dapsone gradually appeared and
became widespread.
 Diagnosis of leprosy

Diagnosis of leprosy is most commonly based on the clinical signs and symptoms. These are easy 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 centre. 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:
 skin lesion consistent with leprosy and with definite sensory loss, with or without thickened
nerves
 positive skin smears
The skin lesion can be single or multiple, usually less pigmented than the surrounding normal skin.
Sometimes the lesion is reddish or copper-coloured. 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. The skin
lesion may show loss of sensation to pin pick and/or light touch. Thickened nerves, mainly peripheral
nerve trunks constitute another feature of leprosy. A thickened nerve is often accompanied by other signs
as a result of damage to the nerve. These may be loss of sensation in the skin and weakness of muscles
supplied 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. 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 appropriate
staining.
A person presenting with skin lesions or with symptoms suggestive of nerve damage, in whom 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 the centre if signs persist for more than six months or if at any time worsening is noticed.
Suspect cases may be also sent to referral clinics with more facilities for diagnosis.

Classification of leprosy

Leprosy can be classified on the basis of clinical manifestations and skin smear results. In the
classification based on skin smears, patients showing negative smears at all sites are grouped as
paucibacillary leprosy (PB), while those showing positive smears at any site are grouped as having
multibacillary leprosy (MB).
However, in practice, most programmes use clinical criteria for classifying and deciding the appropriate
treatment regimen for individual patients, particularly in view of the non-availability or non-dependability
of the skin-smear services. The clinical system of classification for the purpose of treatment includes the
use of number of skin lesions and nerves involved as the basis for grouping leprosy patients into
multibacillary (MB) and paucibacillary (PB) leprosy.
While classifying leprosy, it is particularly important to ensure that patients with multibacillary disease
are not treated with the regimen for the paucibacillary form of the disease.
Transmission of leprosy

Leprosy is known to occur at all ages ranging from early infancy to very old age. The youngest age
reported for occurrence of leprosy is three weeks in Martinique (Montestruc & Berdonneau, 1954). The
youngest case seen by the author was in an infant of two-and-a-half months, where the diagnosis of
leprosy was confirmed by histopathology. Occurrence of leprosy, presumably for the first time, is not
uncommon even after the age of seventy.
Method of transmission of leprosy
The exact mechanism of transmission of leprosy is not known. At least until recently, the most widely
held belief was that the disease was transmitted by contact between cases of leprosy and healthy persons.
More recently the possibility of transmission by the respiratory route is gaining ground. There are also
other possibilities such as transmission through insects which cannot be completely ruled out.
Sex distribution
Although leprosy affects both sexes, in most parts of the world males are affected more frequently than
females often in the ratio of 2:1. This preponderance of males is observed in as diverse geographic
situations as India, the Philippines, Hawaii, Venezuela and Cameroon. Doull et al (1942) from their
studies in the Philippines have also pointed out that the difference as a true difference due to higher
incidence among males, and not due to differing duration of disease for the two sexes. It it were the latter
case, the sex-specific prevalence could be different even with the same sex-specific incidence. It should
be pointed out that the male preponderance in leprosy is not universal and there are several areas,
particularly in Africa, where there is either equal occurrence of leprosy in the two sexes, or occasionally
even a higher prevalence among females. Such situations have been observed in Uganda, Nigeria,
Malawi, Gambia, Burkina Faso, Zambia, Thailand and Japan.

Microbiology of M.leprae

M.leprae

The aetiological agent of leprosy is Mycobacterium leprae. It is a strongly acid-fast rod-shaped organism
with parallel sides and rounded ends. In size and shape it closely resembles the tubercle bacillus. It occurs
 in large numbers in the lesions of lepromatous leprosy, chiefly in masses within the lepra cells, often
grouped together like bundles of cigars or arranged in a palisade. Chains are never seen. Most striking are
the intracellular and extra-cellular masses, known as globi, which consist of clumps of bacilli in capsular
material. Under the electron microscope the bacillus appears to have a great variety of forms. The
commonest is a slightly curved filament 3-10 m in length containing irregular arrangements of dense
material sometimes in the shape of rods. Short rod-shaped structures can also be seen (identical with the
rod-shaped inclusions within the filaments) and also dense spherical forms. Some of the groups of bacilli
can be seen to have a limiting membrane.
It is believed that only leprosy bacilli which stain with carbol-fuchsin as solid acid-fast rods are viable
and that bacilli which stain irregularly are probably dead and degenerating. The differences are valuable
pointers in biopsy specimens to the effects of treatment. In patients receiving standard multidrug therapy
(MDT), a very high proportion of bacilli are killed within days, which suggests that many of the
manifestations of leprosy, including reactions of the erythema nodosum type, which follow initial
treatment, must be due in part to antigens from dead organisms rather than living bacilli. We therefore
need drugs which will help the body to dispose of dead but still intact leprosy bacilli.
Two indices which depend on observation of M. leprae in smears from skin or nasal smears are useful in
assessing the amount of infection, and the viability of the organisms and also the progress of the patient
under treatment. They are the morphological index and the bacteriological index.
The bacteriological index (BI)
This is an expression of the extent of bacterial loads. It is calculated by counting six to eight stained
smears under the 100 x oil immersion lens. in a smear made by nicking the skin with a sharp scalpel and
scraping it; the fluid and tissue obtained are spread fairly thickly on a slide and stained by the Ziehl-
Neelsen method and decolorized (but not completely) which 1% acid alcohol. The results are expressed
on a logarithmic scale.
 1+ At least 1 bacillus in every 100 fields.
 2+ At least 1 bacillus in every 10 fields.
 3+ At least 1 bacillus in every field.
 4+ At least 10 bacilli in every field.
 5+ At least 100 bacilli in every field.
 6+ At least 1000 bacilli in every field.
The bacteriological index is valuable because it is simple and is representative of many lesions but is
affected by the depth of the skin incision, the thoroughness of the scrape and the thickness of the film.
A more accurate and reliable index of the bacillary content of a lesion is given by the logarithmic index of
biopsies (LIB. These indices help to assess the state of patients at the beginning of treatment and to assess
progress.
The morphological index (MI)
This is calculated by counting the numbers of solid-staining acid-fast rods. Only the solid-staining bacilli
are viable. It is not unusual for solid-staining M. leprae to reappear for short periods in patients being
successfully treated with drugs. It is important to recognize that measurement of MI is liable for observer
variations and therefore not always reliable.

Prevalence of leprosy

The global registered prevalence of leprosy at the beginning of 2006 was 219,826 cases. There are now
only six countries that have still to reach the elimination target of 1 case per 10,000 population, at the
 national level. The table below shows the registered prevalence of these six countries over the period
2004-2006. Note that rates shown for prevalence is for 1 case per 10,000 population.
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Rates of prevalence and new case detection (shown in parenthesis) were calculated based on population
data for the year 2005 from United Nations Population Division ) (2004 Revision:
POP/DB/WPP/Rev.2004/2/F1)

Research

Until the early 1980s, the chemotherapy of leprosy consisted of using dapsone monotherapy for the
control of the disease. This was usually administered as 100 mg daily for a minimum period of 5 years to
treat paucibacillary leprosy, and for life long to treat multibacillary leprosy. Dapsone being a slow acting
and weak bactericidal drug, lead to wide-spread poor patient compliance and the emergence of dapsone
resistant strains of Mycobacterium leprae.

This period of failure and frustration changed dramatically with the introduction of greatly improved
treatment through the application of combinations of drugs referred to as multidrug therapy (MDT),
which was first recommended by a WHO Study Group in 1981. These regimens include a combination of
rifampicin, clofazimine and dapsone for multibacillary leprosy and rifampicin plus dapsone for
paucibacillary leprosy. This therapy has proved to be the most reliable and practical method of treating
leprosy.

The recommendations on MDT received enthusiastic support from most of the leprosy-endemic countries,
WHO regional committees, international and non-governmental organizations (NGOs), donor agencies
and professional bodies alike. Follow-up based on sufficiently large number of patients has revealed very
low relapse rates following stopping treatment. (A cumulative risk of less than 1% over a nine year
period, both for MB and PB leprosy)

KEY FACTS
 Leprosy is a chronic disease caused by a bacillus, Mycobacterium leprae. Official figures show
that more than 213 000 people mainly in Asia and Africa are infected, with approximately 249 000 new
cases reported in 2008.
 M. leprae multiplies very slowly and the incubation period of the disease is about five years.
Symptoms can take as long as 20 years to appear.
 Leprosy is not highly infectious. It is transmitted via droplets, from the nose and mouth, during
close and frequent contacts with untreated cases.
 Untreated, leprosy can cause progressive and permanent damage to the skin, nerves, limbs and
eyes. Early diagnosis and treatment with multidrug therapy (MDT) remain the key elements in
eliminating the disease as a public health concern.
 Elimination of leprosy as a public health problem
In 1991 WHO's governing body, the World Health Assembly (WHA) passed a resolution to eliminate
leprosy as a public health problem by the year 2000. Elimination of leprosy as a public health problem is
defined as a prevalence rate of less than one case per 10 000 persons. The target was achieved on time
and the widespread use of MDT reduced the disease burden dramatically.
 Over the past 20 years, more than 14 million leprosy patients have been cured, about 4 million
since 2000.
 The prevalence rate of the disease has dropped by 90% – from 21.1 per 10 000 inhabitants to less
than 1 per 10 000 inhabitants in 2000.
 Dramatic decrease in the global disease burden: from 5.2 million in 1985 to 805 000 in 1995 to
753 000 at the end of 1999 to 213 036 cases at the end of 2008.
 Leprosy has been eliminated from 119 countries out of 122 countries where the disease was
considered as a public health problem in 1985.
 So far, there has been no resistance to antileprosy treatment when used as MDT.
 Efforts currently focus on eliminating leprosy at a national level in the remaining endemic
countries and at a sub-national level from the others.
Actions and resources required
In order to reach all patients, treatment of leprosy needs to be fully integrated into general health services.
This is a key to successful elimination of the disease. Moreover, political commitment needs to be
sustained in countries where leprosy remains a public health problem. Partners in leprosy elimination also
need to continue to ensure that human and financial resources are made available for the elimination of
leprosy.
The age-old stigma associated with the disease remains an obstacle to self-reporting and early treatment.
The image of leprosy has to be changed at the global, national and local levels. A new environment, in
which patients will not hesitate to come forward for diagnosis and treatment at any health facility, must
be created.
Strategy for leprosy elimination
The following actions are part of the ongoing leprosy elimination campaign:
 ensuring accessible and uninterrupted MDT services available to all patients through flexible and
patient-friendly drug delivery systems;
 ensuring the sustainability of MDT services by integrating leprosy services into the general health
services and building the ability of general health workers to treat leprosy;
 encouraging self-reporting and early treatment by promoting community awareness and changing
the image of leprosy;
 monitoring the performance of MDT services, the quality of patients’ care and the progress being
made towards elimination through national disease surveillance systems.
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Related links 
 Leprosy elimination
 Global leprosy situation, 2009
 WHO Leprosy Forum Report [pdf 230kb]