Although leprosy has been eliminated (<1 case per 10 000 population) in South Africa since 1926, new cases continue to be reported, say experts, whose retrospective study analysed the clinical data of patients and the competencies of healthcare practitioners in treating the disease.
Describing their findings in the SA Medical Journal, the team, led by researchers from the Nelson R Mandela Medical School at the University of KwaZulu-Natal, found that not only were patient adherence and an absence of education on the disease problematic, but so was the fact that there was insufficient training of health workers.
Leprosy, also known as Hansen’s disease, is a chronic infection caused by Mycobacterium leprae and Mycobacterium lepromatosis.
Notably, despite the prevalence of HIV in sub-Saharan Africa, studies have disproved a direct link between HIV infection and leprosy – but it manifests as an immune reconstitution disease in HIV-positive patients, typically presenting in paucibacillary leprosy with a type 1 reaction.
According to the WHO, the most recent worldwide prevalence of leprosy was 22.9 cases per million, with a significant burden in Africa.
In South Africa, leprosy’s distribution is heterogenous, with historical concentrations in specific regions: the prevalence in this country is 0.013 per 10 000 population, with male predominance, a high percentage of multibacillary cases, and challenges with treatment completion.
This study offers insights into the comprehensive characteristics, clinical presentations and management strategies employed for leprosy cases in KwaZulu-Natal over 20 years. Notably, a male predominance was observed, consistent with global and local research findings.
The average age at diagnosis, ~37.8-years-old, placed patients in the middle age group, a trend corroborated by prior studies. Although there were limited paediatric and geriatric cases, an intriguing observation was that nearly 60% of paediatric patients had household contacts.
The study revealed a disproportionate burden of leprosy among black South Africans, particularly in comparison with other population groups within KwaZulu-Natal. Conversely, <8% of the patients were foreign nationals, a notable contrast to a recent study conducted in Gauteng, where more than half of the patient cohort consisted of foreign nationals.
This discrepancy may be attributed to Gauteng’s status as an economic hub, attracting more migrant workers.
HIV co-infection
Considering the high prevalence of HIV in KwaZulu-Natal, with recent studies reporting rates as high as 27%, the identification of 15% of leprosy patients as HIV positive and 17% with an unknown HIV status underscores the imperative for prioritising HIV testing among individuals presenting with leprosy.
Medical comorbidities other than HIV, such as tuberculosis, hypertension, diabetes, asthma, thyroid disease, epilepsy and hepatitis, were present in ~12% of the patient population, with a noteworthy proportion (almost 11%) of geriatric patients.
Leprosy classification
Almost 90% of patients were diagnosed with multibacillary leprosy, with 60% of the cohort exhibiting lepromatous leprosy, attributed to KwaZulu-Natal’s larger rural population, potentially leading to delayed presentations to healthcare services.
Common symptoms included upper respiratory tract symptoms, hair loss and nerve pain. The predilection of lesions on exposed sites such as the face, limbs and trunk was noted, consistent with findings in other studies.
Neurological complications were evident in over one-fifth of patients, with clawing of the hands being the most frequent complication. This contrasts with a study conducted in the USA, where one-third of the cohort exhibited neurological complications.
Other severe features such as digital auto-amputation, leonine facies and collapsed nasal bridges were also noted in some patients. Ocular complications were relatively infrequent, predominantly comprising conjunctivitis and lagophthalmosis, findings echoing those of a similar study in Cameroon.
Most patients (99.5%) received MDT, with only one person refusing MDT, and opting for dapsone monotherapy, a concerning development with potential implications for public health.
A significant concern was that 27% failed to complete their treatment, contributing to a substantial public health challenge, as these individuals may serve as potential sources of transmission within the community.
Treatment reactions were observed in one-third of patients, with type 2 reactions comprising the majority (59%).
Possible reasons for defaulting treatment may include limited access to healthcare services, socio-economic challenges, non-compliance due to treatment reactions and side effects, stigma and the impact of Covid-19 restrictions.
Recent studies involving patients with pulmonary tuberculosis in our setting showed higher rates of completion of treatment in patients who participated in directly observed therapy short course (DOTS).
Similar results were noted in patients with leprosy globally. This could serve as a cost-effective and simple solution to prevent loss to follow-up.
The reseachers said the study’s findings shed light on the multi-faceted aspects of leprosy within KwaZulu-Natal, emphasising the need for targeted strategies to improve diagnosis, treatment adherence and overall management of this ancient and stigmatised disease in the region.
Limitations
The study had several limitations that warrant consideration. First, the possibility of reporter, recall and selection bias cannot be entirely ruled out as data were collected by a sole researcher and relied upon reported information. Second, the patient files contained gaps in critical data, including HIV status and the extent of involvement of the greater auricular nerve.
Files also lacked data regarding BCG vaccination, and the team was unable to ascertain whether post-exposure prophylaxis was offered to contacts. Other gaps in data included documentation of re-challenging treatment after treatment reactions and the cause of relapse.
A threat to public health
The researchers said their study underscores a stark reality: despite being eliminated in SA – according to the WHO – leprosy persists, with new cases emerging in KwaZulu-Natal.
The misconception that leprosy is an ancient, biblical ailment has fostered a dangerous complacency among healthcare practitioners and the general public. These findings highlight the fact the disease remains a tangible threat to public health, disproportionately affecting the most vulnerable members of society.
The researchers said a diligent and unwavering commitment was vital to combat this ongoing challenge, that healthcare workers should be empowered with the requisite skills to educate patients about the disease and its management, and actively engage communities.
They have called for enhancement of health information systems: issues related to health information systems in SA contribute to the burden of leprosy-related complications. To address this, they recommend implementation of electronic health records to improve patient data tracking, management and continuity of care.
Additionally, they encourage capacity building for healthcare workers, among whom there is a deficiency in leprosy-specific skills; enhancement of health information systems; comprehensive healthcare worker and patient education initiatives, with emphasis on community engagement and public education on leprosy; and greater focus on contact tracing and prophylaxis. More effort and resources should be directed toward prevention of leprosy transmission in the community.
Future research avenues could include exploring patient perspectives on leprosy, investigating health system factors, assessing long-term treatment outcomes and evaluating the impact of community engagement and public education initiatives.
Recommendations include more research regarding cost-effective solutions, such as the use of DOTS to prevent loss to follow-up.
These studies would contribute valuable insights to the ongoing efforts to combat leprosy
A leprosy-free status can only be achieve only through the collective involvement of all stakeholders and the cultivation of a collaborative spirit, they said.
Study details
Characteristics, clinical manifestations and management of leprosy in KwaZulu-Natal: a 20-year retrospective study
J S Sons, Z N Mkhize, N C Dlova, C Aldous, P R Bhat, A V Chateau.
Published in the SA Medical Journal in May 2024
Objectives
To describe the biographical profile, clinical manifestations and treatment outcomes in patients with leprosy in KwaZulu-Natal Province.
Methods
This retrospective study aimed to analyse the clinical data of leprosy patients in SA from 2002 to 2022. Data collected included patient demographics, comorbidities, cutaneous and neurological manifestations of leprosy, complications, treatment and adverse reactions. Descriptive statistics were used to summarise the data.
Results
The study analysed the clinical data of 194 leprosy patients from 2002 to 2022, most of whom were male and middle aged, with a disproportionate representation of black South Africans. Regarding socio-economic status, 80% were unemployed and 40% were social grant recipients. The majority of the cases were clustered in urban centres and diagnosed at secondary care facilities, with 15% being HIV positive: most patients (90%) were classified as having multibacillary leprosy. Common symptoms included upper respiratory tract involvement, hair loss and painful nerves, with the face and limbs being most frequently affected. Cutaneous morphology predominantly included plaques and hypopigmented patches, while neurological signs included ulnar nerve tenderness, muscle weakness and sensory deficits. Debilitating neurological complications were found in one-fifth of patients. Despite initiation of multidrug therapy in most patients, a significant proportion (27.3%) did not complete the full course of treatment, and treatment reactions were noted in 33.5% of them.
Conclusion
These findings emphasise the urgent need for enhanced patient and healthcare worker education, particularly in primary healthcare settings, to improve adherence to treatment, advocate for prophylactic measures and prevent new cases. Achieving leprosy-free status in SA requires the collaboration of many role-players to address these challenges and improve healthcare practices.
JS Sons, MB ChB – Department of Dermatology, King Edward VIII Hospital, University of KwaZulu-Natal, Nelson R Mandela School of Clinical Medicine; Z N Mkhize, MB ChB, FC Derm – Department of Dermatology, Harry Gwala Regional Hospital, Pietermaritzburg, Nelson R Mandela School of Medicine; N Dlova, FC Derm (SA), PhD – Department of Dermatology, King Edward VIII Hospital, UKZN, Nelson R Mandela School of Clinical Medicine; C Aldous, PhD – Department of Clinical Medicine, Nelson R Mandela School of Medicine, UKZN; P R Bhat, MD, DNB – Department of Dermatology, Father Muller Medical College, Mangalore, Karnataka, India; A V Chateau, FC Derm (SA), MMedSci – Department of Dermatology, Grey’s Hospital, Nelson R Mandela School of Medicine, UKZN.
PubMed article – Leprosy in Mpumalanga Province, South Africa – eliminated or hidden?
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