Brazil is the 2nd country with the most cases of leprosy in the world – 02/06/2023 – Health

Dermatologist Marco Andrey Cipriani Frade works with leprosy patients and has studied the disease for over 25 years.

He is a professor at the Faculty of Medicine of USP in Ribeirão Preto, in the interior of São Paulo, and currently chairs the Brazilian Society of Hansenology.

In mid-2008, upon returning from a post-doctorate in Holland, the specialist felt something strange. Two of his toes began to tingle as he walked along a beach. Shortly afterwards, a region of the thigh lost hair and became numb.

“As I didn’t want to self-diagnose myself, I looked for two colleagues and reported this loss of sensitivity. They said it was probably nothing much, just ‘thing in my head'”, he reports.

The laboratory tests that the doctor did also did not allow any definitive conclusion.

Not satisfied, Frade went to talk to his boss at the university. “She examined it, she said it was leprosy and it needed to be treated,” he says.

The story of the dermatologist, who is himself one of the country’s leading experts on the subject, reflects a reality that is little publicized. Brazil is still the second country in the world with the most cases of leprosy — it is second only to India.

To make matters worse, difficulties in recognizing the most frequent symptoms of this disease and the lack of awareness on the subject make it difficult to make an early diagnosis of a condition for which there is treatment and cure.

an ancient disease

Leprosy is described in medical treatises in India from the 6th century BC. It also appears in several passages in the New Testament of the Bible, still under the name by which it was known in the past: leprosy.

In the Gospel of Mark, for example, there is a passage where a “leper” approaches Jesus Christ and asks to be healed.

“And Jesus, moved with compassion, reached out his hand, touched him […] Soon the leprosy disappeared and [ele] was clean”, says the text.

In Europe during the Middle Ages, individuals with the disease were expelled from cities and forced to walk with a bell to announce the passage.

Many were interned in “leprosariums” or “lazarettos”, institutions that continued (and continue) to exist in many places —including in Brazil.

In short, leprosy is caused by the bacteria mycobacterium leprae. It is spread through droplets of saliva and frequent, close contact with an infected individual.

This micro-organism has a preference for the coldest places on the body – such as elbows, knees, feet and earlobes –, where there is less blood circulation.

He usually hides in the peripheral nerves, which are just under the skin, and can remain there for years or decades before manifesting any symptoms.

“About 90% of the population manages to defend itself well against the pathogen. But there are 10% who, due to immunity, will develop the disease”, estimates physician Egon Daxbacher, coordinator of the Leprosy Department of the Brazilian Society of Dermatology.

The name leprosy, by the way, refers to the Norwegian scientist Gerhard Hansen, who discovered the pathogen and identified it as the cause of the disease in the 19th century.

Another striking characteristic of Mycobacterium leprae is the time it takes to reproduce: while other bacteria generate offspring in 12 or 24 hours, this species has a slow replication process, which takes up to 15 days.

This slowness helps to understand one of the most striking characteristics of the disease: the years or decades it takes to manifest itself and cause the most serious effects on the body.

A threat more real than you might think

Although this disease seems like a memory from the past, statistics show a completely different reality: the latest epidemiological bulletin from the Ministry of Health, published on May 11, reveals that 18,318 Brazilians were diagnosed with leprosy in 2021.

This represents 13% of all cases registered in the world —according to the World Health Organization (WHO), there were 140,594 patients detected with Mycobacterium leprae across the planet that year.

In the document, the Ministry of Health analyzes leprosy notifications in the country between 2010 and 2021.

The good news is that the rate of new cases is falling: in most states, this rate has decreased. The disease only continues to be considered “hyperendemic” (when there are more than 10 cases per 100,000 inhabitants) in Tocantins and Mato Grosso.

It is also “very high” (5 to 9.99 cases per 100,000 inhabitants) in Maranhão and Piauí.

To complete, eight states have a “high” rate (2.5 to 4.99 cases) in the North, Northeast and Midwest regions.

Daxbacher indicates that the sharpest decline observed in the last two or three years should not be viewed with so much optimism. “I would really like this to indicate an improvement in the situation, but there is certainly an effect of the Covid-19 pandemic on the decrease in leprosy diagnoses”, he assesses.

In other words: as we are talking about a slow-progressing disease, the tendency is for the statistics to change little by little.

In the dermatologist’s view, major epidemiological changes in such a short space of time reflect more the urgency related to the coronavirus, which required a diversion in efforts and resources from the entire health sector.

a forgotten reality

Frade makes another point about these newly released numbers.

He recalls that, in the early 2000s, the WHO launched a strategy to reduce leprosy across the globe — the goal was to have less than one case per ten thousand inhabitants and thus remove the disease from the list of major health problems. public.

“And this actually happened in a large part of the world. But Brazil did not reach this goal”, highlights the dermatologist.

“However, with the global goal reached, the active search campaigns for new cases stopped taking place and the medical faculties themselves started to no longer talk about leprosy with new students”, he recalls.

This easing of the measures even made sense from an international point of view — however, in the particular case of Brazil and other nations that fell by the wayside and did not see the expected decrease, leprosy lost the attention it had been receiving.

And that, in turn, meant that cases and transmissions continued to happen in the background, without due care from regional, national and international health institutions.

“The data that appears in the epidemiological bulletins is nothing more, nothing less, than the representation of reality. The issue is that trained professionals today know little about when to suspect leprosy”, says Frade.

Why Brazil?

But what makes our country one of the leaders in the global leprosy ranking even today?

Daxbacher explains that the disease is closely related to poverty and places where several people share the same house.

“India, Brazil and Indonesia are very populous countries with large urban clusters, where a large part of the population lives”, he contextualizes.

The dermatologist recalls that the bacteria that cause the disease is transmitted through breathing and depends on constant contact.

“The most affected people are very close to each other and live in houses with few rooms and low ventilation. This is still the reality of part of the Brazilian population and of these other countries”, he adds.

And this, of course, is combined with the fact that leprosy is a disease that receives less attention from public policies.

Without diagnosis and treatment, those infected continue transmitting the bacteria for many years – which perpetuates its transmission chains in the community.

But Frade recalls that the disease can affect people of any social class. According to him, leprosy is indeed linked to poverty, but it is not exclusive to the less favored.

“We have many patients from the middle or upper class who undergo countless magnetic resonances or ultrasounds and it takes decades to have an adequate diagnosis”, he points out.

Symptoms beyond the skin

Frade also draws attention to the fact that the symptoms of leprosy are broader than what is known by the popular imagination —in general terms, people think that it only causes deforming skin lesions.

“We need to remember the neurological manifestations of this disease”, says the professor at USP in Ribeirão Preto.

He even estimates that classic skin lesions appear in less than 30% of the most recent cases.

“People suffer for a long time with other neurological symptoms and there is enormous difficulty in recognizing them as a sign of suspicion”, he laments.

Other leprosy-related discomforts that go beyond the skin include numbness and tingling in specific parts of the body (especially hands, arms, feet, legs and face), loss of sensation in patches of skin, cramps and pain.

And all these signs of infection have practical repercussions on the quality of life and health of those affected.

“It’s the housewife who touches the hot pan and doesn’t feel anything. She will only notice the blister on her skin later, while she takes a shower. Or the mechanic who can no longer thread a screw with his fingertips”, exemplifies Frade.

As time passes—and the destruction of nerves by Mycobacterium leprosy—, there is loss of movement, deformations and other secondary complications.

“There are patients who wear a shoe with a stone inside and don’t even realize it. They will only realize something is wrong when they see the sock full of blood at the end of the day”, he recalls.

“In addition to these unnoticed injuries, they increase the risk of other infections, which sometimes even require amputation”, adds the doctor.

The dermatologist points out that, in the official WHO definitions, the diagnosis of leprosy is made from a trio of manifestations:

• Lesions in areas of the skin with alteration in thermal, painful and/or tactile sensitivity
• Peripheral nerve thickening, associated with sensory, motor and/or autonomic changes
• Presence of bacilli mycobacterium leprae in exams

“If there is one of these three factors, even if the test is negative, it is necessary to think about leprosy”, clarifies Frade.

Daxbacher ponders that the heart of the matter is early detection. “If we carry out the diagnosis in the first stages, the patient may only present neurological complaints without manifestations in the skin”, she says.

“Therefore, it is important to go to the health service for an evaluation if you have persistent numbness in parts of the body or the appearance of spots on the skin, especially those that do not burn, do not itch and do not hurt”, he advises.

These symptoms can be anything from diabetes to a herniated disc, from ringworm to dermatitis. But they also suggest the onset of leprosy.

Once the diagnosis is made, the treatment is relatively simple and is available to all Brazilians in the Unified Health System (SUS). Depending on the stage and degree of involvement, the doctor will prescribe two or three antibiotics, which are taken for six to 12 months.

This therapeutic scheme has curative power — but patients who have already had deep nerve injuries often do not recover 100% of the movements or function of the feet, hands and other parts of the body, unfortunately.

How to reduce cases

Daxbacher points out that, in recent months, the Ministry of Health has updated the strategy to deal with leprosy.

“A novelty that is already underway in several states is the implementation of a rapid test that will allow the monitoring of the relatives of individuals who have been diagnosed with the disease”, he summarizes.

“The idea is to follow these people more closely over the years to check whether they have become infected. From there, it is possible to make earlier detection and start treatment”, he adds.

The hope is that this contact tracing will make it possible to catch cases in the early stages and prevent the creation of new transmission chains for Mycobacterium leprae in the community — so that, in the future, there will be lower and lower rates of this disease in the country.

For Frade, leprosy will cease to be a public health problem in Brazil when doctors, nurses and other specialists are better trained on the problem.

“It is necessary to educate and train health professionals so that they do not have prejudices and are able to recognize the three cardinal signs of leprosy”, he concludes.

This text was originally published here.