Leprosy 44700 225640775 2008-07-14T18:11:16Z 68.14.66.235 {{DiseaseDisorder infobox | Name = Leprosy (Hansen's Disease) | Image = Leprosy.jpg | Caption = A 24-year-old man infected with leprosy. | ICD10 = {{ICD10|A|30| |a|30}} | ICD9 = {{ICD9|030}} | ICDO = | DiseasesDB = 8478 | OMIM = 246300 | MedlinePlus = 001347 | eMedicineSubj = med | eMedicineTopic = 1281 | eMedicine_mult = {{eMedicine2|derm|223}} {{eMedicine2|neuro|187}} | MeshName = Leprosy | MeshNumber = C01.252.410.040.552.386 | }} {{dablink|For the malady found in the Hebrew Bible, see [[Tzaraath]]. For the album by the band Death, see [[Leprosy (album)]].}} '''Leprosy''' (from the Greek lepid, meaning scales on a fish), or '''Hansen's disease''', is a [[Chronic (medical)|chronic]] [[infectious disease]] caused by the [[Bacteria|bacterium]] ''[[Mycobacterium leprae]]''.<ref name=Sasaki_2001>{{cite journal |author=Sasaki S, Takeshita F, Okuda K, Ishii N |title=Mycobacterium leprae and leprosy: a compendium |journal=Microbiol Immunol |volume=45 |issue=11 |pages=729–36 |year=2001 |url = http://www.jstage.jst.go.jp/article/mandi/45/11/729/_pdf |pmid=11791665}}</ref> Leprosy is primarily a [[granuloma]]tous disease of the [[Peripheral nervous system|peripheral nerves]] and [[Mucous membrane|mucosa]] of the [[upper respiratory tract]]; skin lesions are the primary external symptom.<ref name=Sherris /> Left untreated, leprosy can be progressive, causing permanent damage to the skin, nerves, limbs, and eyes. Contrary to popular conception,<ref>[http://organizedwisdom.com/Leprosy Leprosy] OrganzedWisdom.com</ref> leprosy does not cause body parts to simply fall off. Historically, leprosy has affected humanity since at least 600 BC, and was well-recognized in the civilizations of [[History of China|ancient China]], [[ancient Egypt|Egypt]] and [[History of India|India]].<ref name=WHO_Factsheet>{{cite web | title = Leprosy | work = WHO | url = http://www.who.int/mediacentre/factsheets/fs101/en/ | accessdate = 2007-08-22}}</ref> In 1995, the [[World Health Organization]] (WHO) estimated that between two and three million people were permanently disabled because of leprosy.<ref name=WHO_1995>{{cite journal |author=WHO|title=Leprosy disabilities: magnitude of the problem |journal=Weekly Epidemiological Record |volume=70 |issue=38 |pages=269–75 |year=1995 |pmid=7577430}}</ref> Although the forced [[quarantine]] or segregation of patients is unnecessary&mdash;and can be considered [[Ethics|unethical]]&mdash;a few [[leper colony|leper colonies]] still remain around the world, in countries such as [[India]], [[Japan]], [[Egypt]], [[Argentina]], and [[Vietnam]]. It is now commonly believed that many of the people who were segregated into these communities were presumed to have leprosy, when they actually had [[syphilis]]. Leprosy which is not contagious would not have spread through a community where syphilis which has similar symptoms is contagious. The age-old [[social stigma]] associated with the advanced form of leprosy lingers in many areas, and remains a major obstacle to self-reporting and early treatment. Effective treatment for leprosy appeared in the late 1930s with the introduction of [[dapsone]] and its derivatives. However, leprosy bacilli resistant to dapsone gradually [[Antibiotic resistance|evolved]] and became widespread, and it was not until the introduction of multidrug therapy (MDT) in the early 1980s that the disease could be diagnosed and treated successfully within the community.{{Fact|date=November 2007}} ==Characteristics== [[Image:Leprosy thigh demarcated cutaneous lesions.jpg|right|thumb|Cutaneous leprosy lesions on a patient's thigh.]] The clinical symptoms of leprosy vary but primarily affect the skin, nerves, and [[mucous membrane]]s.<ref name=Naafs_2001>{{cite journal |author=Naafs B, Silva E, Vilani-Moreno F, Marcos E, Nogueira M, Opromolla D |title=Factors influencing the development of leprosy: an overview |journal=Int J Lepr Other Mycobact Dis |volume=69 |issue=1 |pages=26–33 |year=2001 |pmid=11480313}}</ref> Patients with this chronic infectious disease are classified as having '''paucibacillary Hansen's disease''' (tuberculoid leprosy), '''multibacillary Hansen's disease''' (lepromatous leprosy), or borderline leprosy. Contrary to popular belief, Hansen's bacillus does not cause rotting of the flesh; rather, a long investigation by [[Paul Wilson Brand|Paul Brand]] yielded that insensitivity in the limbs extremities was the reason why unfelt wounds or lesions, however minute, lead to undetected deterioration of the tissues, the lack of pain not triggering an immediate response as in a fully functioning body.<ref name=Brand_1997>{{cite book | last = Brand | first = Paul | authorlink = Paul Wilson Brand | coauthors = Philip Yancey | title = The gift of pain : why we hurt & what we can do about it | publisher = Zondervan Publ. | date = c1997 | isbn = 0-310-22144-7}}</ref> Recently, leprosy has also emerged as a problem in [[HIV]] patients on [[antiretroviral drug]]s.<ref name=McNeil_2006>{{cite news | author = McNeil Jr DG|title = Worrisome New Link: AIDS Drugs and Leprosy |url = http://www.nytimes.com/2006/10/24/health/24lepr.html | work = New York Times |date= 2006-10-24 |accessdate=2007-05-07 }}</ref> == Classification == There is some confusion over classification because the WHO replaced an older, more complicated classification system with a simpler system that identifies two subtypes of leprosy - paucibacillary and multibacillary. The older system included six categories: Indeterminate Leprosy, Borderline Tuberculoid Leprosy, Midborderline Leprosy, Borderline Lepromatous Leprosy, Lepromatous Leprosy, and Tuberculoid Leprosy. Paucibacillary leprosy encompasses indeterminate, tuberculoid, and borderline tuberculoid leprosy. It is characterized by one or more [[Hypopigmentation|hypopigmented]] skin [[macule]]s and anaesthetic patches, i.e., damaged peripheral nerves that have been attacked by the human host's immune cells. Multibacillary leprosy includes midborderline, borderline lepromatous, and lepromatous leprosy. It is associated with symmetric skin [[lesion]]s, [[Nodule (medicine)|nodules]], [[Plaque (dermatology)|plaque]]s, thickened dermis, and frequent involvement of the nasal mucosa resulting in nasal congestion and [[epistaxis]] (nose bleeds) but typically detectable nerve damage is late. Borderline leprosy is of intermediate severity and is the most common form. Skin lesions resemble tuberculoid leprosy but are more numerous and irregular; large patches may affect a whole limb, and peripheral nerve involvement with weakness and loss of sensation is common. This type is unstable and may become more like lepromatous leprosy or may undergo a reversal reaction, becoming more like the tuberculoid form. ==Cause== {{main|Mycobacterium leprae}} [[Image:M leprae ziehl nielsen2.jpg|thumb|right|''Mycobacterium leprae'', the causative agent of leprosy. As [[acid-fast]] bacteria, ''M. leprae'' appear red when a [[Ziehl-Neelsen stain]] is used.]] ''Mycobacterium leprae'' is the causative agent of leprosy.<ref name=Sherris>{{cite book | author = Ryan KJ, Ray CG (editors) | title = Sherris Medical Microbiology | edition = 4th ed. | pages = 451-3 | publisher = McGraw Hill | year = 2004 | isbn = 0838585299}}</ref> An intracellular, [[acid-fast]] [[Bacteria|bacterium]], ''M. leprae'' is [[Aerobic organism|aerobic]], [[Gram-positive bacteria|gram-positive]], and rod-shaped, and is surrounded by the waxy [[cell membrane]] coating characteristic of ''[[Mycobacterium]]'' species.<ref name=Baron>{{cite book | author = McMurray DN | title = Mycobacteria and Nocardia. ''in:'' Baron's Medical Microbiology ''(Baron S ''et al'', eds.)| edition = 4th ed. | publisher = Univ of Texas Medical Branch | year = 1996 | url = http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=mmed.section.1833 | isbn = 0-9631172-1-1 }}</ref> Due to extensive loss of [[gene]]s necessary for independent growth, ''M. leprae'' is [[Microbiological culture|unculturable]] in the laboratory, a factor which leads to difficulty in definitively identifying the organism under a strict interpretation of [[Koch's postulates]].<ref>{{cite journal |author=Bhattacharya S, Vijayalakshmi N, Parija SC |title=Uncultivable bacteria: Implications and recent trends towards identification |journal=Indian journal of medical microbiology |volume=20 |issue=4 |pages=174–7 |year=2002 |pmid=17657065 |url=http://www.ijmm.org/article.asp?issn=0255-0857;year=2002;volume=20;issue=4;spage=174;epage=177;aulast=Bhattacharya}}</ref> The use of non-culture-based techniques such as [[molecular genetics]] has allowed for alternative establishment of causation. == Pathophysiology == The exact mechanism of transmission of leprosy is not known: prolonged close contact and transmission by nasal droplet have both been proposed, and, while the latter fits the pattern of disease, both remain unproven.<ref>{{cite journal |author=Reich CV |title=Leprosy: cause, transmission, and a new theory of pathogenesis |journal=Rev. Infect. Dis. |volume=9 |issue=3 |pages=590–4 |year=1987 |pmid=3299638 |doi=}}</ref> The only other animals besides humans known to contract leprosy are the [[armadillo]], [[chimpanzee]], [[Sooty Mangabey|sooty mangabey]], and [[Crab-eating Macaque|cynomolgus macaque]].<ref>{{cite journal |author=Rojas-Espinosa O, Løvik M |title=Mycobacterium leprae and Mycobacterium lepraemurium infections in domestic and wild animals |journal=Rev. - Off. Int. Epizoot. |volume=20 |issue=1 |pages=219–51 |year=2001 |pmid=11288514 |doi=}}</ref> The bacterium can also be grown in the laboratory by injection into the footpads of mice.<ref>{{cite journal |author=Hastings RC, Gillis TP, Krahenbuhl JL, Franzblau SG |title=Leprosy |journal=Clin. Microbiol. Rev. |volume=1 |issue=3 |pages=330–48 |year=1988 |pmid=3058299 |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=3058299}}</ref> There is evidence that not all people who are infected with ''M. leprae'' develop leprosy, and genetic factors have long been thought to play a role, due to the observation of clustering of leprosy around certain families, and the failure to understand why certain individuals develop lepromatous leprosy while others develop other types of leprosy.<ref>{{cite journal |author=Alcaïs A, Mira M, Casanova JL, Schurr E, Abel L |title=Genetic dissection of immunity in leprosy |journal=Curr. Opin. Immunol. |volume=17 |issue=1 |pages=44–8 |year=2005 |pmid=15653309 |doi=10.1016/j.coi.2004.11.006}}</ref> It is estimated that due to genetic factors, only 5 percent of the population is susceptible to leprosy.<ref>{{cite web |url=http://www.kfsm.com/Global/story.asp?S=7845322 |title=AR Dept of Health debunks leprosy fears |date=2008-02-08 |accessdate=2008-04-08}}</ref> This is mostly because the body is naturally immune to the bacteria, and those persons who do become infected are experiencing a severe allergic reaction to the disease. However, the role of genetic factors is not entirely clear in determining this clinical expression. In addition, malnutrition and prolonged exposure to infected persons may play a role in development of the overt disease. The incubation period for the bacteria can last anywhere from two to ten years. The most widely held belief is that the disease is transmitted by contact between infected persons and healthy persons.<ref>{{cite journal |author=Kaur H, Van Brakel W |title=Dehabilitation of leprosy-affected people--a study on leprosy-affected beggars |journal=Leprosy review |volume=73 |issue=4 |pages=346–55 |year=2002 |pmid=12549842 |doi=}}</ref> In general, closeness of contact is related to the dose of infection, which in turn is related to the occurrence of disease. Of the various situations that promote close contact, contact within the household is the only one that is easily identified, although the actual incidence among contacts and the relative risk for them appear to vary considerably in different studies. In [[Incidence (epidemiology)|incidence studies]], infection rates for contacts of lepromatous leprosy have varied from 6.2 per 1000 per year in [[Cebu]], [[Philippines]]<ref name=Doull_1942>{{cite journal | author = Doull JA, Guinto RA, Rodriguez RS, et al. | title = The incidence of leprosy in Cordova and Talisay, Cebu, Philippines | journal = International Journal of Leprosy | year = 1942 | volume = 10 | pages = 107–131 | url= }}</ref> to 55.8 per 1000 per year in a part of Southern [[India]].<ref name=Noordeen_1978>{{cite journal |author=Noordeen S, Neelan P |title=Extended studies on chemoprophylaxis against leprosy |journal=Indian J Med Res |volume=67 |issue= |pages=515–27 |year=1978 |pmid=355134}}</ref> Two exit routes of ''M. leprae'' from the human body often described are the skin and the nasal mucosa, although their relative importance is not clear. It is true that lepromatous cases show large numbers of organisms deep down in the [[dermis]]. However, whether they reach the skin surface in sufficient numbers is doubtful. Although there are reports of [[Acid-fast|acid-fast bacilli]] being found in the desquamating [[epithelium]] of the skin, Weddell ''et al'' have reported that they could not find any acid-fast bacilli in the [[Epidermis (skin)|epidermis]], even after examining a very large number of specimens from patients and contacts.<ref name=Weddell_1963>{{cite journal |author=Weddell G, Palmer E |title=The pathogenesis of leprosy. An experimental approach |journal=Leprosy Review |volume=34 |issue= |pages=57–61 |year=1963 |pmid=13999438}}</ref> In a recent study, Job ''et al'' found fairly large numbers of ''M. leprae'' in the superficial [[keratin]] layer of the skin of lepromatous leprosy patients, suggesting that the organism could exit along with the [[Sebaceous gland|sebaceous]] secretions.<ref name=Job_1999>{{cite journal |author=Job C, Jayakumar J, Aschhoff M |title="Large numbers" of Mycobacterium leprae are discharged from the intact skin of lepromatous patients; a preliminary report |journal=Int J Lepr Other Mycobact Dis |volume=67 |issue=2 |pages=164–7 |year=1999 |pmid=10472371}}</ref> The importance of the nasal mucosa was recognized as early as 1898 by Schäffer, particularly that of the ulcerated mucosa.<ref name=Schaffer_1898>''Arch Dermato Syphilis'' 1898; 44:159–174</ref> The quantity of bacilli from nasal mucosal lesions in lepromatous leprosy was demonstrated by Shepard as large, with counts ranging from 10,000 to 10,000,000.<ref name=Shepard_1960>{{cite journal |author=Shepard C |title=Acid-fast bacilli in nasal excretions in leprosy, and results of inoculation of mice |journal=Am J Hyg |volume=71 |issue= |pages=147–57 |year=1960 |pmid=14445823}}</ref> Pedley reported that the majority of lepromatous patients showed leprosy bacilli in their nasal secretions as collected through blowing the nose.<ref name=Pedley_1973>{{cite journal |author=Pedley J |title=The nasal mucus in leprosy |journal=Lepr Rev |volume=44 |issue=1 |pages=33–5 |year=1973 |pmid=4584261}}</ref> Davey and Rees indicated that nasal secretions from lepromatous patients could yield as much as 10 million viable organisms per day.<ref name=Davey_1974>{{cite journal |author=Davey T, Rees R |title=The nasal dicharge in leprosy: clinical and bacteriological aspects |journal=Lepr Rev |volume=45 |issue=2 |pages=121–34 |year=1974 |pmid=4608620}}</ref> The entry route of ''M. leprae'' into the human body is also not definitely known. The two seriously considered are the skin and the upper respiratory tract. While older research dealt with the skin route, recent research has increasingly favored the respiratory route. Rees and McDougall succeeded in the experimental transmission of leprosy through aerosols containing ''M. leprae'' in immune-suppressed mice, suggesting a similar possibility in humans.<ref name=Rees_1977>{{cite journal |author=Rees R, McDougall A |title=Airborne infection with Mycobacterium leprae in mice |journal=J Med Microbiol |volume=10 |issue=1 |pages=63–8 |year=1977 |pmid=320339}}</ref> Successful results have also been reported on experiments with [[Nude mouse|nude mice]] when ''M. leprae'' were introduced into the nasal cavity by topical application. <ref name=Chehl_1985>{{cite journal |author=Chehl S, Job C, Hastings R |title=Transmission of leprosy in nude mice |journal=Am J Trop Med Hyg |volume=34 |issue=6 |pages=1161–6 |year=1985 |pmid=3914846}}</ref> In summary, entry through the respiratory route appears the most probable route, although other routes, particularly broken skin, cannot be ruled out. The CDC notes the following assertion about the transmission of the disease: "''Although the mode of transmission of Hansen's disease remains uncertain, most investigators think that ''M. leprae'' is usually spread from person to person in respiratory droplets''."<ref name=CDC_2005>{{cite web | title = Hansen's Disease (Leprosy) | work = Technical Information | publisher = Centers for Disease Control and Prevention | date= 2005-10-12 | url = http://www.cdc.gov/ncidod/dbmd/diseaseinfo/hansens_t.htm | accessdate = 2007-03-22}}</ref> In leprosy both the reference points for measuring the [[incubation period]] and the times of infection and onset of disease are difficult to define; the former because of the lack of adequate immunological tools and the latter because of the disease's slow onset. Even so, several investigators have attempted to measure the incubation period for leprosy. The minimum incubation period reported is as short as a few weeks and this is based on the very occasional occurrence of leprosy among young infants. <ref name=Montestruc_1954>{{cite journal |author=Montestruc E, Berdonneau R |title=2 New cases of leprosy in infants in Martinique. |journal=Bull Soc Pathol Exot Filiales |volume=47 |issue=6 | language = French | pages=781–3 |year=1954 |pmid=14378912}}</ref> The maximum incubation period reported is as long as 30 years, or over, as observed among war veterans known to have been exposed for short periods in endemic areas but otherwise living in non-endemic areas. It is generally agreed that the average incubation period is between 3 to 5 years. == Treatment == [[Image:Blisters01.jpg|thumb|left|MDT patient packs and blisters]] Until the development of [[dapsone]], [[rifampicin]], and [[clofazimine]] in the 1940s, there was no effective cure for leprosy. However, dapsone is only weakly bactericidal against ''[[Mycobacterium leprae|M. leprae]]'' and it was considered necessary for patients to take the drug indefinitely. Moreover, when dapsone was used alone, the ''M. leprae'' population quickly [[evolution|evolved]] [[antibiotic resistance]]; by the 1960s, the world's only known anti-leprosy drug became virtually useless. The search for more effective anti-leprosy drugs than dapsone led to the use of clofazimine and rifampicin in the 1960s and 1970s.<ref name=Rees_1970>{{cite journal | author= Rees RJ, Pearson JM, Waters MF | title=Experimental and clinical studies on rifampicin in treatment of leprosy | journal=Br Med J | year=1970 | pages=89–92 | volume= 688 | issue= 1 | pmid=4903972}}</ref> Later, Indian scientist Shantaram Yawalkar and his colleagues formulated a combined therapy using rifampicin and dapsone, intended to mitigate bacterial resistance.<ref name=Yawalkar_1982>{{cite journal | author=Yawalkar SJ, McDougall AC, Languillon J, Ghosh S, Hajra SK, Opromolla DV, Tonello CJ | title=Once-monthly rifampicin plus daily dapsone in initial treatment of lepromatous leprosy | journal=Lancet | year=1982 | pages=1199–1202 | volume= 8283 | issue= 1 | pmid = 6122970 | doi=10.1016/S0140-6736(82)92334-0}}</ref> Multidrug therapy (MDT) and combining all three drugs was first recommended by a WHO Expert Committee in 1981. These three anti-leprosy drugs are still used in the standard MDT regimens. None of them is used alone because of the risk of developing resistance. Because this treatment is quite expensive, it was not quickly adopted in most endemic countries. In 1985 leprosy was still considered a public health problem in 122 countries. The 44th World Health Assembly (WHA), held in Geneva in 1991 passed a resolution to eliminate leprosy as a public health problem by the year 2000 — defined as reducing the global [[prevalence]] of the disease to less than 1 case per 100,000. At the Assembly, the World Health Organization (WHO) was given the mandate to develop an elimination strategy by its member states, based on increasing the geographical coverage of MDT and patients’ accessibility to the treatment. The WHO Study Group's report on the ''Chemotherapy of Leprosy'' in 1993 recommended two types of standard MDT regimen be adopted.<ref name=WHO_1993>{{cite web | title = Chemotherapy of Leprosy | work = WHO Technical Report Series 847 | publisher = WHO | date= 1994 | url = http://www.who.int/lep/mdt/chemotherapy/en/index.html | accessdate = 2007-03-24}}</ref> The first was a 24-month treatment for multibacillary (MB or lepromatous) cases using rifampicin, clofazimine, and dapsone. The second was a six-month treatment for paucibacillary (PB or tuberculoid) cases, using rifampicin and dapsone. At the First International Conference on the Elimination of Leprosy as a Public Health Problem, held in Hanoi the next year, the global strategy was endorsed and funds provided to WHO for the procurement and supply of MDT to all endemic countries. [[Image:MDTRegimens.jpg|thumb|400px|right|MDT anti-leprosy drugs: standard regimens]] Between 1995 and 1999, WHO, with the aid of the [[Nippon Foundation]] (Chairman [[Yōhei Sasakawa]], [[World Health Organization Goodwill Ambassador]] for Leprosy Elimination), supplied all endemic countries with free MDT in blister packs, channelled through Ministries of Health. This free provision was extended in 2000 with a donation by the MDT manufacturer Novartis, which will run until at least the end of 2010. At the national level, [[Non-governmental organization|non-government organizations]] (NGOs) affiliated to the national programme will continue to be provided with an appropriate free supply of this WHO supplied MDT by the government. MDT remains highly effective and patients are no longer infectious after the first monthly dose.<ref name="WHO_Factsheet" /> It is safe and easy to use under field conditions due to its presentation in calendar blister packs.<ref name="WHO_Factsheet" /> [[Relapse]] rates remain low, and there is no known [[Antibiotic resistance|resistance]] to the combined drugs.<ref name="WHO_Factsheet" /> The Seventh WHO Expert Committee on Leprosy, <ref name=WHO_1998>{{cite web | title = Seventh WHO Expert Committee on Leprosy| work = WHO Technical Report Series 874 | publisher = WHO | date= 1998 | url = http://www.who.int/lep/resources/expert/en/index.html | accessdate = 2007-03-24}}</ref> reporting in 1997, concluded that the MB duration of treatment—then standing at 24 months—could safely be shortened to 12 months "without significantly compromising its efficacy." Persistent obstacles to the elimination of the disease include improving detection, educating patients and the population about its cause, and fighting social taboos about a disease for which patients have historically been considered "unclean" or "cursed by God" as outcasts. Where taboos are strong, patients may be forced to hide their condition (and avoid seeking treatment) to avoid discrimination. The lack of awareness about Hansen's disease can lead people to falsely believe that the disease is highly contagious and incurable. The [[ALERT (medical facility, Ethiopia)|ALERT]] hospital and research facility in Ethiopia provides training to medical personnel from around the world in the treatment of leprosy, as well as treating many local patients. Surgical techniques, such as for the restoration of control of movement of thumbs, have been developed there. == Prevention == A single dose of [[rifampicin]] is able to reduce the rate of leprosy in contacts by 57% to 75%.<ref>{{cite journal|author=Moet FJ, Pahan D, Oskam L, Richardus JH|title=Effectiveness of single dose rifampicin in preventing leprosy in close contacts of patients with newly diagnosed leprosy: cluster randomised controlled trial|journal=BMJ|year=2008|doi=10.1136/bmj.39500.885752.BE | volume = 336 | pages = 761|pmid=18332051}}</ref><ref>{{cite journal|author=Bakker MI, Hatta M, Kwenang A, ''et al.''|title=Prevention of leprosy using rifampicin as chemoprophylaxis|journal=Am J Trop Med Hyg|year=2005|volume=72|pages=443&ndash;8|url=http://www.ajtmh.org/cgi/content/abstract/72/4/443?ijkey=4b15a78b876fd990dfd877ee89b22399c026501c&keytype2=tf_ipsecsha|pmid=15827283}}</ref> [[Bacillus Calmette-Guérin|BCG]] is able to offer a variable amount of protection against leprosy as well as against [[tuberculosis]].<ref>{{cite journal |author=Fine PE, Smith PG |journal=Lepr Rev |volume=67 |issue=4 |year=1996 |pages=249&ndash;252 |pmid=9033195}}</ref><ref>{{cite journal |author=Karonga prevention trial group |title=Randomized controlled trial of single BCG, repeated BCG, or combined BCG and killed ''Mycobacterium leprae'' vaccine for prevention of leprosy and tuberculosis in Malawi |journal=Lancet |volume=348 |year=1996 |pages=17&ndash;24 |pmid=8691924 |doi=10.1016/S0140-6736(96)02166-6}}</ref> == Epidemiology == [[Image:Lepra 2003.png|350px|thumb|World distribution of leprosy, 2003.]] Worldwide, two to three million people are estimated to be permanently disabled because of Hansen's disease.<ref name=WHO_1995 /> [[India]] has the greatest number of cases, with [[Brazil]] second and [[Myanmar]] third. In 1999, the world [[Incidence (epidemiology)|incidence]] of Hansen's disease was estimated to be 640,000; in 2000, 738,284 cases were identified. In 1999, 108 cases occurred in the [[United States]]. In 2000, the [[World Health Organization]] (WHO) listed 91 countries in which Hansen's disease is [[endemic (epidemiology)|endemic]]. [[India]], [[Myanmar]] and [[Nepal]] contained 70% of cases. In 2002, 763,917 new cases were detected worldwide, and in that year the WHO listed [[Brazil]], [[Madagascar]], [[Mozambique]], [[Tanzania]] and [[Nepal]] as having 90% of Hansen's disease cases. According to recent figures from the WHO, new cases detected worldwide have decreased by approximately 107,000 cases (or 21%) from 2003 to 2004. This decreasing trend has been consistent for the past three years. In addition, the global registered prevalence of HD was 286,063 cases; 407,791 new cases were detected during 2004. Hansen's disease is tracked by the [[Centers for Disease Control and Prevention]] (CDC). Its [[prevalence]] in the United States is believed to be rising and underreported.<ref>{{cite news | author = Levis W | date= 2007-05-20 | url = http://transcripts.cnn.com/TRANSCRIPTS/0705/20/ldtw.01.html |title = Leprosy rising | work = CNN}}</ref> Although the number of cases worldwide continues to fall, pockets of high prevalence continue in certain areas such as [[Brazil]], [[South Asia]] ([[India]], [[Nepal]]), some parts of Africa ([[Tanzania]], [[Madagascar]], [[Mozambique]]) and the western [[Pacific Ocean|Pacific]]. === Risk groups === At highest risk are those living in endemic areas with poor conditions such as inadequate bedding, contaminated water and insufficient diet, or other diseases (such as [[HIV]]) that compromise immune function. Recent research suggests that there is a defect in cell-mediated immunity that causes susceptibility to the disease. Less than ten percent of the world's population is actually capable of acquiring the disease {{Fact|date=January 2008}}. The region of [[DNA]] responsible for this variability is also involved in [[Parkinson's disease]]{{Fact|date=July 2008}}, giving rise to current speculation that the two disorders may be linked in some way at the [[biochemistry|biochemical]] level. In addition, men are twice as likely to contract leprosy as women. According to The Leprosy Mission Canada, most people – about 95% of the population – are naturally immune . === Disease burden === Although annual [[Incidence (epidemiology)|incidence]]—the number of new leprosy cases occurring each year—is important as a measure of transmission, it is difficult to measure in leprosy due to its long incubation period, delays in diagnosis after onset of the disease and the lack of laboratory tools to detect leprosy in its very early stages. Instead, the registered [[prevalence]] is used. Registered prevalence is a useful proxy indicator of the disease burden as it reflects the number of active leprosy cases diagnosed with the disease and retrieving treatment with MDT at a given point in time. The prevalence rate is defined as the number of cases registered for MDT treatment among the population in which the cases have occurred, again at a given point in time.<ref name=WHO_1985>{{cite journal |author= |title=Epidemiology of leprosy in relation to control. Report of a WHO Study Group |journal=World Health Organ Tech Rep Ser |volume=716 |issue= |pages=1–60 |year=1985 |pmid=3925646}}</ref> New case detection is another indicator of the disease that is usually reported by countries on an annual basis. It includes cases diagnosed with onset of disease in the year in question (true incidence) and a large proportion of cases with onset in previous years (termed a backlog prevalence of undetected cases). The new case detection rate (NCDR) is defined by the number of newly detected cases, previously untreated, during a year divided by the population in which the cases have occurred. Endemic countries also report the number of new cases with established disabilities at the time of detection, as an indicator of the backlog prevalence. However, determination of the time of onset of the disease is generally unreliable, is very labour-intensive and is seldom done in recording these statistics. === Global situation === {| class = "prettytable" style = "float:center; font-size:85%; margin-left:15px" | + colspan="7" | '''Table 1:''' Prevalence at beginning of 2006, and trends in new case detection 2001-2005, excluding Europe |- !rowspan=2|Region !colspan=1 width=160|Registered Prevalence (rate/10,000 pop.) !colspan=5 width=400|New Case Detection during the year |- ! Start of 2006 !! 2001 !! 2002 !! 2003 !! 2004 !! 2005 |- | align="left" | Africa | 40,830 (0.56) || 39,612 || 48,248 || 47,006 || 46,918 || 42,814 |- | align="left" | [[Americas]] | 32,904 (0.39) || 42,830 || 39,939 || 52,435 || 52,662 || 41,780 |- | align="left" | [[South-East Asia]] | 133,422 (0.81) || 668,658 || 520,632 || 405,147 || 298,603 || 201,635 |- | align="left" | Eastern Mediterranean | 4,024 (0.09) || 4,758 || 4,665 || 3,940 || 3,392 || 3,133 |- | align="left" | [[Pacific Ocean|Western Pacific]] | 8,646 (0.05) || 7,404 || 7,154 || 6,190 || 6,216 || 7,137 |- |- style="border: 1px solid #BFA3A3; margin: auto" bgcolor="#F5FFFC" | background:#F2CECE | align="left" |Totals | NA || 763,262 || 620,638 || 514,718 || 407,791 || 296,499 |} {| class = "prettytable" style = "float:center; font-size:85%; margin-left:15px" | + colspan="7" | '''Table 2:''' Prevalence and Detection, countries still to reach elimination |- !rowspan=2|Countries !colspan=3 width=240|Registered Prevalence (rate/10,000 pop.) !colspan=3 width=240|New Case Detection (rate/100,000 pop.) |- ! Start of 2004 !! Start of 2005 !! Start of 2006 !! During 2003 !! During 2004 !! During 2005 |- | align="left" |{{BRA}} | 79,908 (4.6) || 30,693 (1.7) || 27,313 (1.5) || 49,206 (28.6) || 49,384 (26.9) || 38,410 (20.6) |- | align="left" |{{MOZ}} | 6,810 (3.4) || 4,692 (2.4) || 4,889 (2.5) || 5,907 (29.4) || 4,266 (22.0) || 5,371 (27.1) |- | align="left" |{{ NPL}} | 7,549 (3.1) || 4,699 (1.8) || 4,921 (1.8) || 8,046 (32.9) || 6,958 (26.2) || 6,150 (22.7) |- | align="left" |{{TZA}} | 5,420 (1.6) || 4,777 (1.3) || 4,190 (1.1) || 5,279 (15.4) || 5,190 (13.8) || 4,237 (11.1) |- style="border: 1px solid #BFA3A3; margin: auto" bgcolor="#F5FFFC" | background:<tt>#F2CECE | align="left" |Totals | NA || NA || NA || NA || NA || NA |} As reported to [[World Health Organization|WHO]] by 115 countries and territories in 2006, and published in the Weekly Epidemiological Record the global registered [[prevalence]] of leprosy at the beginning of the year was 219,826 cases. <ref name=WHO_2006>{{cite journal | author = | title = Global leprosy situation, 2006 | journal = Weekly Epidemiological Record | year = 2006 | volume = 81 | number = 32 | pages =309&ndash;16 | url= http://www.who.int/lep/resources/wer8132.pdf}}</ref> New case detection during the previous year (2005 - the last year for which full country information is available) was 296,499. The reason for the annual detection being higher than the prevalence at the end of the year can be explained by the fact that a proportion of new cases complete their treatment within the year and therefore no longer remain on the registers. The global detection of new cases continues to show a sharp decline, falling by 110,000 cases (27%) during 2005 compared with the previous year. '''Table 1''' shows that global annual detection has been declining since 2001. The African region reported an 8.7% decline in the number of new cases compared with 2004. The comparable figure for the Americas was 20.1%, for South-East Asia 32% and for the Eastern Mediterranean it was 7.6%. The Western Pacific area, however, showed a 14.8% increase during the same period. '''Table 2''' shows the leprosy situation in the four major countries which have yet to achieve the goal of elimination at the national level. It should be noted that: a) Elimination is defined as a prevalence of less than 1 case per 10,000 population; b) Madagascar reached elimination at the national level in September 2006; c) Nepal detection reported from mid-November 2004 to mid-November 2005; and d) D.R. Congo officially reported to WHO in 2008 that it had reached elimination by the end of 2007, at the national level. <br clear="all" /> == History == Numerous ''leprosaria'', or leper hospitals, sprang up in the [[Middle Ages]]; [[Matthew Paris]] estimated that in the early thirteenth century there were 19,000 across Europe.<ref>{{CathEncy|wstitle=Leprosy}}</ref> The first recorded leprosarium was in [[Harbledown]]. (See [[Leper colony]].) These institutions were run along monastic lines and, while lepers were encouraged to live in these monastic-type establishments, this was for their own health as well as quarantine. Indeed, some medieval sources indicate belief that those suffering from leprosy were considered to be going through [[Purgatory]] on Earth, and for this reason their suffering was considered more holy than the ordinary person's. More frequently, lepers were seen to exist in a place between life and death: they were still alive, yet many chose or were forced to [[Separatio Leprosorum|ritually separate themselves]] from mundane existence.<ref>Brody, Saul Nathaniel (1974). The Disease of the Soul: Leprosy in Medieval Literature. Ithaca: Cornell Press.</ref> [[Radegund]] was noted for washing the feet of lepers. [[Orderic Vitalis]] writes of a monk, Ralf, who was so overcome by the plight of lepers that he prayed to catch leprosy himself (which he eventually did). The leper would carry a clapper and bell to warn of his approach, and this was as much to attract attention for charity as to warn people that a diseased person was near. [[Image:Gerhard Hansen.jpg|thumb|right|[[Gerhard Armauer Hansen|G. H. A. Hansen]], discoverer of ''[[Mycobacterium leprae|M. leprae]]'']] ''[[Mycobacterium leprae]]'', the causative agent of leprosy, was discovered by [[Gerhard Armauer Hansen|G. H. Armauer Hansen]] in [[Norway]] in 1873, making it the first bacterium to be identified as causing disease in humans.<ref name=Hansen_1874>{{cite journal | author = Hansen GHA | title = Undersøgelser Angående Spedalskhedens Årsager (Investigations concerning the etiology of leprosy) | journal = Norsk Mag. Laegervidenskaben | year = 1874 | volume = 4| pages = pp. 1–88 | language = Norwegian }}</ref><ref name=Irgens_2002>{{cite journal |author=Irgens L |title=The discovery of the leprosy bacillus |journal=Tidsskr Nor Laegeforen |volume=122 |issue=7 |pages=708–9 |year=2002 |pmid=11998735}}</ref> He worked at ''St. Jørgens Hospital'' in [[Bergen]], founded early in the fifteenth century. St. Jørgens is today a museum, ''Lepramuseet'', probably the best preserved leprosy hospital in Northern Europe.<ref>http://www.bymuseet.no/?vis=80</ref> Historically, individuals with Hansen's disease have been known as ''lepers'', however, this term is falling into disuse as a result of the diminishing number of leprosy patients and the [[wikt:pejorative|pejorative]] connotations of the term. The term most widely accepted among people and agencies working in the field of Hansen's disease is "people affected by Hansen's disease." Historically, the term ''[[Tzaraath]]'' from the [[Hebrew Bible]] was, erroneously, commonly translated as leprosy, although the symptoms of Tzaraath were not entirely consistent with leprosy and rather referred to a variety of disorders other than Hansen's disease.<ref>Artscroll Tanakh, Leviticus 13:59, 1996</ref> In particular, [[tinea capitis]] ([[Fungus|fungal]] scalp infection) and related infections on other body parts caused by the [[dermatophyte]] fungus ''Trichophyton violaceum'' are abundant throughout the Middle East and North Africa today and might also have been common in biblical times. Similarly, the related agent of the disfiguring skin disease [[favus]], ''Trichophyton schoenleinii'', appears to have been common throughout Eurasia and Africa before the advent of modern medicine. Persons with severe favus and similar fungal diseases (and potentially also with severe [[psoriasis]] and other diseases not caused by microorganisms) tended to be classed as having leprosy as late as the 17th century in Europe.<ref name=Kane_1997>{{cite book | author = Kane J, Summerbell RC, Sigler L, Krajden S, Land G | title = Laboratory Handbook of Dermatophytes: A clinical guide and laboratory manual of dermatophytes and other filamentous fungi from skin, hair and nails | publisher = Star Publishers (Belmont, CA) | year = 1997 | isbn = 0898631572 }}</ref> This is clearly shown in the painting ''Governors of the Home for Lepers at Haarlem 1667'' by [[Jan de Bray]] ([[Frans Hals Museum]], [[Haarlem]], the [[Netherlands]]), where a young Dutch man with a vivid scalp infection, almost certainly caused by a fungus, is shown being cared for by three officials of a charitable home intended for leprosy sufferers. The use of the word "leprosy" before the mid-19th century, when microscopic examination of skin for medical diagnosis was first developed, can seldom be correlated reliably with Hansen's disease as we understand it today. The word "leprosy" derives from the ancient Greek words ''lepros'', a scale, and ''lepein'', to peel.<ref name=Barnhart_1995>{{cite book | author = Barnhart RK | title = Barnhart Concise Dictionary of Etymology | publisher = Harper Collins | location = New York | year = 1995 | isbn = 0062700847}}</ref> The word came into the English language via Latin and Old French. The first attested English use is in the ''Ancrene Wisse,'' a 13th-century manual for nuns ("Moyseses hond..bisemde o þe spitel uuel & þuhte lepruse." ''The Middle English Dictionary,'' s.v., "leprous"). A roughly contemporaneous use is attested in the Anglo-Norman ''Dialogues of Saint Gregory,'' "Esmondez i sont li lieprous" (''Anglo-Norman Dictionary,'' s.v., "leprus"). ==Popular culture== {{Trivia|date=July 2008}} * In the film ''[[Ben-Hur (1959 film)|Ben-Hur]]'', Judahs' mother and sister suffer from leprosy. * [[R.E.M.]] has a song entitled [[New Test Leper]] on their ''[[New Adventures in Hi-Fi]]'' album. * The book series ''[[The Chronicles of Thomas Covenant, the Unbeliever]]'' revolves around the main character's leprosy. * ''[[The Motorcycle Diaries]]'' depicts Ernesto [[Che Guevera]], at the age of 24, working at the San Pablo leper colony in Peru: 'Che' was a medical student at the time, specializing in leprosy. He wrote of the poor treatment and living conditions of the patients there. This, and other disparities he witnessed, contributed to his strong belief in the need for public health care. * [["Weird Al" Yankovic]] has a song entitled "[[Poodle Hat|Party at the Leper Colony]]", in which he plays with [[expressions]] such as "footloose", "the cat got her tongue" and "don't give me lip". * The King of [[Jerusalem]] in the 12th century, [[Baldwin IV of Jerusalem|Baldwin IV]], suffered from leprosy. This was portrayed in ''[[Kingdom of Heaven (film)|Kingdom of Heaven]]'', a 2005 film directed by [[Ridley Scott]]. The Director's Cut of the film also depicts the king's nephew and heir to the throne, [[Baldwin V of Jerusalem|Baldwin V]], in the early stages of leprosy. * The aging [[Robert de Brus, jure uxoris Earl of Carrick|Robert the Bruce Sr.]] in the 1995 film ''[[Braveheart]]''. * [[Dimmu Borgir]] has a song entitled Lepers Among Us. * The famous Vietnamese poet Han Mac Tu suffered and died from leprosy in the 1930s. * [[David Bowie]] describes [[The Rise and Fall of Ziggy Stardust and the Spiders from Mars|Ziggy Stardust]] as a "leper messiah" in the song "Ziggy Stardust". * The band [[Metallica]] has a song called "Leper Messiah" on their ''[[Master of Puppets]]'' album. * In ''[[The Simpsons]]'' episode "[[Little Big Mom]]", Lisa tricks Homer and Bart into believing that they have leprosy. *Death Metal band [[Death (band)|Death]] has an [[Leprosy (album)|album titled Leprosy]] * The American TV show ''[[House (TV series)|House]]'' featured a young boy with leprosy in Season 1, Episode 13, "Cursed". * The book entitled ''[[Hawaii (novel)|Hawaii]]'' by [[James A. Michener]] tells one story of a Chinese man, Mun Ki, who discovers that he has leprosy, as termed 'mai Pake'. He is then banished to the isolated [[leper colony]] of [[Kalaupapa, Hawaii|Kalawao]] on the island of [[Molokai|Moloka'i]] with other afflicted people.<ref>{{cite book|last= Michener |first= James A. |authorlink= James A. Michener |title= [[Hawaii (novel)|Hawaii]] |origyear= 1959 |series= [[Fawcett Publications|Fawcett Crest Book]] |publisher= [[Ballantine Books]] |location= New York |isbn= 0-449-21335-8 |pages= pp.540-566 |chapter= IV: From the starving village }}</ref> * In an episode of the American sitcom ''[[Seinfeld]]'', Jerry compared the DMV's high concentration of unattractive people to that of a leper colony. * In the song "One" by the rock band U2, Bono sings "Did you come here for forgiveness? Did you come to raise the dead? Did you come here to play Jesus to the lepers in your head?' * An episode of the TV series ''[[Monk (TV series)|Monk]]'' is titled [[Mr. Monk and the Leper]]. * One of the incarnations of the antagonist in [[Stephen King]]'s [[It (novel)|It]] is afflicted with advanced leprosy. * In the original and remake of the [[John Carpenter]] [[film]] ''[[The Fog]]'', a ship carrying a migrating [[leper colony]] is robbed of a fortune to build the fictional Antonio Bay, [[California]], USA. * In the animated film ''[[Princess Mononoke]]'' the leader of Irontown, ''[[Lady Eboshi]]'', takes in lepers and cares for their wounds and provides shelter for them. *The band [[Frightened Rabbit]] wrote a song called "The Modern Leper". *The band [[Opeth]] wrote a song called "The Leper Affinity", and their song, "Blackwater Park", contains the lines "Lepers coiled 'neath the trees, dying men in bewidered soliloquys". * Kenshin Himura of the [[anime]] [[Rurouni Kenshin]] suffered and died of symptoms resembling leprosy in his final days. Though the writers cannot explain his illness, the lesions and the manner of transmission to his wife Kaoru Kamiya resembles that of leprosy. *The book "The Pearl Diver" written by Jeff Talarigo tells the life story of a 19 year old Japanese pearl diver who discovers that she has leprosy and is sent to a leprosarium on the island of Nagashima where she remains for many years, her name stricken from all records as someone better known as dead. *In the 1973 film ''[[Papillon]]'', [[Steve McQueen]] comes across some lepers during one of his escapes from penal colonies. To gain the trust of the lepers McQueen smokes on the leper's cigar, giving the director the opportunity to educate people about non-infectious strains of the bacillus. *In Monty Python's ''[[Life of Brian]]'', a man begging for alms on the street claims to be an ex-leper. When asked about this, he explains he was cured by [[Jesus]]. "One minute I'm a leper with a trade, next minute my livelihood's gone." ==Famous People== *[[Father Damien|Blessed Damien of Moloka'i]] was a Roman Catholic missionary who became a leper when he spent the rest of his life serving in the leper colony at [[Moloka'i]]. *King [[Baldwin IV]] of Jerusalem. * Possibly [[Robert I]] de Brus, [[King of Scots]]. == External links == {{commons|Leprosy}} * [http://www.wilsoncenter.org/index.cfm?topic_id=116811&fuseaction=topics.event_summary&event_id=394034 Leprosy and Human Rights] - event held at Woodrow Wilson International Center for Scholars, March 2008 * [http://www.hrsa.gov/hansens/ National Hansen's Disease Programs (NHDP), U.S. Health Resources and Services Administration] * [http://www.cdc.gov/ncidod/dbmd/diseaseinfo/hansens_t.htm Hansen's Disease (Leprosy)] - [[Centers for Disease Control and Prevention]] * [http://www.who.int/lep/en/ World Health Organization (WHO) leprosy website] * [http://www.leprosy.org/ American Leprosy Missions] * [http://dx.doi.org/10.1371/journal.pmed.0020341 The Global Campaign to Eliminate Leprosy] article from ''PLoS Medicine'' * [http://www.lepra.org.uk LEPRA - Health in Action] UK Based organisation founded in 1924 to treat leprosy and related diseases of poverty. ; History of leprosy * {{cite web | title = History of Leprosy, Urban Environment and French Colonization in West Africa | url = http://halshs.archives-ouvertes.fr/docs/00/25/89/20/PDF/Environnmement_africain_et_maladie-Barges1993.pdf}} * {{cite web | title = Anthropology and History of leprosy | url = http://halshs.archives-ouvertes.fr/docs/00/25/67/25/PDF/HA.pdf | format = ''Histoire & Anthropologie'', 15 (1995) 115-122 }} * [http://www.leprosyhistory.org/ ILA Global Project on the History of Leprosy] * [http://bphc.hrsa.gov/nhdp/NHD_MUSEUM_HISTORY.htm/ National Hansen's Disease Museum] * BBC News: [http://news.bbc.co.uk/2/hi/health/4540461.stm Slave trade key to leprosy spread] * {{cite web | title = Interview with author John Tayman (''The Colony'') | work = IT Conversations Tech Nation | url = http://www.itconversations.com/shows/detail975.html | format = [[MP3|MP3 audio]]: runtime = 00:23:20, 10.7 mb | date= 2006-02-07 | accessdate = 2007-03-22}} ; Research * [http://www.granuloma.homestead.com/leprosy.html Pathology Images of Leprosy and Other Granulomatous diseases] Yale Rosen, M.D. * [http://www.ilep.org.uk/library-resources/ INFOLEP Leprosy Information Services] * [http://www.leprosy-review.org.uk/ ''Leprosy Review''] * {{ cite web | title = Medical anthropology, Leprosy and Health Care in French speaking West-Africa | url = http://halshs.archives-ouvertes.fr/docs/00/25/67/18/PDF/Publication_ALLF_Barges_pour_SHS_.pdf }} * {{ cite web | title = Anthropologie, lèpre et santé publique | url = http://laredoute-occasion.priceminister.com/offer/buy/62340027/Barges-Anne-Lepre-Et-Anthropologie-De-La-Maladie-Au-Mali-Livre.html }} * {{ cite web | title = Gender and Leprosy | url = http://halshs.archives-ouvertes.fr/index.php?halsid=m4gd98pgis2p0vncak9663o107&view_this_doc=halshs-00256724&version=1}} == References == <!-- --------------------------------------------------------------- See http://en.wikipedia.org/wiki/Wikipedia:Footnotes for a discussion of different citation methods and how to generate footnotes using the <ref> & </ref> tags and the {{Reflist}} template -------------------------------------------------------------------- --> {{Reflist|2}} === Further reading === {{refbegin}} * {{cite journal | author = Bargès A | title = Ségrégation antilépreuse et comportements adaptatifs à Bamako (Mali) | work = Environnement urbain et maladie | journal = Ecologie humaine | year = 1993 | volume = 11 | issue = 2 | pages = pp. 7–20 | url= http://halshs.archives-ouvertes.fr/docs/00/25/89/20/PDF/Environnmement_africain_et_maladie-Barges1993.pdf}} * {{cite journal | author = Bargès A | title = Entre conformismes et changements, le monde de la lèpre au Mali | work = Soigner au pluriel | journal = Paris, Editions Karthala | year = 1996 | volume = | issue = | pages = pp. 280–313 | url= http://halshs.archives-ouvertes.fr/docs/00/26/60/96/PDF/Le_monde_la_lepre_1996(1993).pdf}} * {{cite journal | author = Clark E | title = Social Welfare and Mutual Aid in the Medieval Countryside | work = Vill, Guild, and Gentry: Forces of Community in Later Medieval England | journal = The Journal of British Studies | year = 1994 | volume = 33 | issue = 4 | pages = pp. 394–6 | url= http://links.jstor.org/sici?sici=0021-9371(199410)33%3A4%3C381%3ASWAMAI%3E2.0.CO%3B2-L}} * {{cite book | author = Icon Health Publications | title = Leprosy: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References | edition = | publisher = San Diego: Icon Health Publications | year = 2004 | isbn = 0-597-84006-7}} * {{cite book | author = Demaitre L | title = Leprosy in Premodern Medicine: A Malady of the Whole Body | publisher = The Johns Hopkins University Press | location = Baltimore, Maryland | year = 2007 | isbn = 978-0-8018-8613-3 }} * {{cite journal | author = Rawcliffe C | title = Learning to Love the Leper: aspects of institutional Charity in Anglo Norman England | journal = Anglo Norman Studies | year = 2001 | volume = 23 | pages = pp. 233–52 | url= }} * {{cite book | author = Rawcliffe C | title = Leprosy in Medieval England | publisher = Boydell Press | location = Ipswich | year = 2006 | isbn = 1843832739 }} * {{cite book | author = Talarigo J | title = The Pearl Diver: (fiction) young woman with leprosy is exiled to leprosy colony in Japan, 1929 | edition = | publisher = Doubleday | year= 2004 | isbn = 1-4025-8661-2}} * {{cite book | author = Tayman J | title = The Colony : The Harrowing True Story of the Exiles of Molokai | edition = | publisher = Simon & Schuster | year = 2006 | isbn = 0-7432-3300 }} * {{cite book | author = Brennert A | title = Moloka'i:(fiction) young woman with leprosy is exiled to leprosy colony in Hawaii, 1891 | edition = | publisher = St. Martin's Press | year = 2003 | isbn = 0-312-30435-8}} {{Bacterial diseases}} {{Antimycobacterials}} [[Category:Leprosy| Leprosy]] [[Category:Dermatology]] [[Category:Infectious skin diseases]] [[Category:Bacterial diseases]] [[Category:Tropical diseases]] [[Category:Neglected diseases]] {{Link FA|id}} [[ar:جذام (مرض)]] [[az:Cüzəm]] [[bn:কুষ্ঠ]] [[zh-min-nan:Hansen ê pīⁿ]] [[bg:Проказа]] [[ca:Lepra]] [[cs:Lepra]] [[da:Spedalskhed]] [[de:Lepra]] [[es:Lepra]] [[eo:Lepro]] [[eu:Legenar]] [[fa:جذام]] [[fr:Lèpre]] [[gl:Lepra]] [[ko:한센병]] [[hi:कुष्ठ]] [[id:Kusta]] [[is:Holdsveiki]] [[it:Lebbra]] [[he:צרעת]] [[la:Lepra]] [[hu:Lepra]] [[ms:Penyakit kusta]] [[nl:Lepra]] [[ja:ハンセン病]] [[no:Spedalskhet]] [[pl:Trąd]] [[pt:Hanseníase]] [[ro:Lepră]] [[qu:Lliqti unquy]] [[ru:Лепра]] [[simple:Leprosy]] [[sl:Gobavost]] [[su:Lépra]] [[fi:Lepra]] [[sv:Lepra]] [[vi:Bệnh phong cùi]] [[tr:Cüzzam]] [[uk:Проказа]] [[ur:جذام]] [[zh:麻瘋病]]