2. Epidemiology

Leprosy was first described in 600 BC and was recognized in the ancient civilization of China, Egypt, and India. The global prevalence of leprosy has decreased with the widespread use of effective therapy. More than 5 million cases were documented in 1985 and fewer than 300,000 cases 20 years later. Leprosy is spread by person to person contact. Although the most important route is unclear, it is believed that M. leprae is spread either through the inhalation of infectious aerosols or through skin contact with respiratory secretions and wound exudates. Numerous M. leprae are found in the nasal secretions of patients with lepromatous leprosy. M. leprae cannot grow in cell free cultures. Thus laboratory confirmation of leprosy requires histopathologic finding consistent with the clinical disease and either skin test reactivity to lepromin in tuberculoid leprosy or observation of acid fast bacteria in the lesion of patients with lepromatous leprosy [6].

The post millennium development goals have begun in 2015. Achieving the Millennium Development Goals (MDGs) as targets for global development needs to be evaluated. New ongoing and sustainable targets are important for the elimination of neglected tropical diseases (NTD) in Indonesia. This review illustrates the NTD situation in Indonesia and highlights issues under NTD transmission. A multidisciplinary approach is a promising strategy to help marginalized people [7].

Over the past 20 years, more than 16 million leprosy patients have been treated. The prevalence rate of the disease has declined by 99%: from 21.1 cases per 10,000 people in 1983 to 0.2 cases per 10,000 people by 2015. According to official reports received from 138 countries from all WHO regions, the global prevalence of leprosy by the end of 2015 was 176,176 cases (0.18 cases per 10,000 people). The number of new cases reported globally over the last 3 years is as follows: 2015: 211,973 (0.21 new cases per 10,000 people), 2014: 213,899 new cases, and 2013: 215,656 new cases (Figures 1–4; Table 1) [8].

As can be seen from the above table, only three countries reported more than 10,000 cases in 2015: India, Brazil, and Indonesia. With 127,326 new cases, India accounted for 60% of the global new cases; Brazil reported 26.395 new cases, representing 13% of the global new cases; and Indonesia reported 17,202 new cases, 8% of the global case load. In 2016, WHO has launched "Global Leprosy Strategy 2016–2020: Accelerate towards a leprosy-free world" aimed at reviving leprosy control efforts and to avoid disability, especially among children affected by disease in endemic countries. This strategy emphasizes the need for ongoing expertise and increases the number of skilled leprosy staff, increases the participation of affected people in leprosy services, and reduces visible abnormalities—also called G2D defects—as well as the stigma associated with the disease. The targets of the new global strategy to be met by 2020 are [8]:

1. Without a disability among new pediatric patients.

Fourteen countries reported more than 1000 new cases, of which three countries—India, Brazil, and Indonesia—account for more than 80% of all the cases in the world [2]. The World Health Organization (WHO) reported that there were approximately 213,899 newly diagnosed patients in 2014 (a detection rate of 3.0/100,000 population), with 94% of LPs located in only 13 countries, one of which was Indonesia [3]. Indonesia's Ministry of Health reported 16,131 newly diagnosed cases of leprosy in 2014. On the other hand, the Department of Health found 498 cases of pauci-bacillary leprosy and 3337 cases of multi-bacillary leprosy [2]; the highest number of which were found in the Jember district. The Global Leprosy Strategy 2016–2020 released in April 2016 underscored its goal of "accelerating towards a leprosy-free world" and its commitment to an approach based on the principles of initiating action, ensuring accountability, and promoting inclusion [4]. The Global Leprosy 2016–2020 aims to detect early leprosy and prompt treatment to prevent disability and reduce transmission of infection in the community. The proportion of G2D cases (2 degree disability) among newly diagnosed patients and G2D levels in a population indicates the efficiency of early leprosy detection. They also showed indirectly the level of awareness of early signs of leprosy, access to leprosy services, and the skills of health care staff in diagnosing leprosy. This strategy is designed to achieve the long-term goal of a "leprosy free world," which refers to situations where societies are free of morbidity, disability, and social consequences due to leprosy [3]. Since 1980 era, Leprosy remains a problem in public health in Indonesia. The program implemented in Indonesia reduced the prevalence to 17,539 cases in 2000. The prevalence was 86% decreased in a 15-year period. It has been noted that a significant increase in leprosy control is due to the large-scale promotion of leprosy prevention and multidrug therapy (MDT) in more than 5600

Leprosy was first described in 600 BC and was recognized in the ancient civilization of China, Egypt, and India. The global prevalence of leprosy has decreased with the widespread use of effective therapy. More than 5 million cases were documented in 1985 and fewer than 300,000 cases 20 years later. Leprosy is spread by person to person contact. Although the most important route is unclear, it is believed that M. leprae is spread either through the inhalation of infectious aerosols or through skin contact with respiratory secretions and wound exudates. Numerous M. leprae are found in the nasal secretions of patients with lepromatous leprosy. M. leprae cannot grow in cell free cultures. Thus laboratory confirmation of leprosy requires histopathologic finding consistent with the clinical disease and either skin test reactivity to lepromin in tuberculoid leprosy or observation of acid fast bacteria in the lesion of patients with lepromatous leprosy [6]. The post millennium development goals have begun in 2015. Achieving the Millennium Development Goals (MDGs) as targets for global development needs to be evaluated. New ongoing and sustainable targets are important for the elimination of neglected tropical diseases (NTD) in Indonesia. This review illustrates the NTD situation in Indonesia and highlights issues under NTD transmission. A multidisciplinary approach is a promising strategy to

primary health centers in Indonesia [5].

4 Current Topics in Tropical Emerging Diseases and Travel Medicine

2. Epidemiology

help marginalized people [7].


Figure 1. Madarosis on facial region in Lucio phenomenon's patient.

Figure 2. Infiltrate and atrophic on auricularis dextra region in Lucio phenomenon's patient.

Figure 3. Ulcer on lower extremities in Lucio phenomenon's patient.

In some areas in Indonesia, leprosy is still prevalent even though the infectious disease is no longer a mystery and can be prevented and treated by adopting a clean and healthy lifestyle. Cases of leprosy continue to surface in some areas, and people who were afflicted with the disease but have been cured continue to face the stigma and discrimination. Health workers

encounter difficulties in reaching out to people living with leprosy to offer treatment. Although Indonesia has managed to reach a stage close to eliminating leprosy, the country has not been able to completely eradicate the disease. In some areas, such as Banten, West

Table 1. New case detection trends in countries that reported >1000 new cases in the past 5 years.

Figure 4. Histopathological examination with Wade Faraco staining in Lucio phenomenon's patient showed multiple

Bangladesh 3848 3970 3688 3141 3622 3976 Brazil 34,894 33,955 33,303 31,044 31,064 26,395 Democratic Republic of the Congo 5049 3949 3607 3744 3272 4237 Ethiopia 4430 NR 3776 4374 3758 3970 India 126,800 127,295 134,752 126,913 125,785 127,326 Indonesia 17,012 20,023 18,994 16,856 17,025 17,202 Madagascar 1520 1577 1474 1569 1617 1487 Myanmar 2936 3082 3013 2950 2877 2571 Nepal 3118 3184 3492 3225 3046 2751 Nigeria 3913 3623 3805 3385 2983 2892 Philippines 2041 1818 2150 1729 1655 1617 Sri Lanka 2027 2178 2191 1990 2157 1977 Mozambique 1207 1097 758 NR NR 1335 United Republic of Tanzania 2349 2288 2528 2005 1947 2256 Total (%) 211,144 (92) 208,039 (92) 217,531 (93) 202,925 (94) 200,808 (94) 199,992 (95) Global total 228,474 226,626 232,857 215,656 213,899 210,758

2010 2011 2012 2013 2014 2015

Leprosy: The Ancient and Stubborn Disease http://dx.doi.org/10.5772/intechopen.79984 7

bacilli commonly in lepromatous leprosy.

Country Number of new cases detected

Figure 4. Histopathological examination with Wade Faraco staining in Lucio phenomenon's patient showed multiple bacilli commonly in lepromatous leprosy.


Table 1. New case detection trends in countries that reported >1000 new cases in the past 5 years.

In some areas in Indonesia, leprosy is still prevalent even though the infectious disease is no longer a mystery and can be prevented and treated by adopting a clean and healthy lifestyle. Cases of leprosy continue to surface in some areas, and people who were afflicted with the disease but have been cured continue to face the stigma and discrimination. Health workers

Figure 3. Ulcer on lower extremities in Lucio phenomenon's patient.

Figure 2. Infiltrate and atrophic on auricularis dextra region in Lucio phenomenon's patient.

6 Current Topics in Tropical Emerging Diseases and Travel Medicine

encounter difficulties in reaching out to people living with leprosy to offer treatment. Although Indonesia has managed to reach a stage close to eliminating leprosy, the country has not been able to completely eradicate the disease. In some areas, such as Banten, West Kalimantan, South Kalimantan, and East Java, leprosy remains prevalent. Tangerang District Health apparatuses in Banten province recently conducted a leprosy census and found that as many as 397 patients with leprosy were in need of serious attention. Leprosy remains a largely neglected disease, especially in the rural areas of the country, where little is known about it, and many suffer from the stigma and lack of knowledge surrounding the disease. East Java provincial Health Office Chief Dr. Harsono remarked in Surabaya that the local government would continue to take steps to reduce the number of leprosy patients and hoped that the figure will come down to less than one patient per 10,000 population. Leprosy has been around since the beginning of time, often surrounded by terrifying, negative stigma, and tales of leprosy patients being shunned as outcasts [9]. The 5-year strategy was launched previously: Strategy "The last impetus for eliminating leprosy as a public health problem" (2000–2005) aimed at eliminating leprosy as a public health problem at the country level. This is data-making and the general public, communications, and campaigns. All countries with a population of one million or more have achieved leprosy eradication as a public health problem at the national level [10].

are genetic, household size, and gender. People living in households with more than seven

Leprosy: The Ancient and Stubborn Disease http://dx.doi.org/10.5772/intechopen.79984 9

Leprosy onset is insidious. It is about the nerves, skin, and eyes. It can also attack the mucosa (mouth, nose, and pharynx), testes, kidneys, smooth/smooth muscle, reticulo-endothelial system, and vascular endothelium. Germs enter the body usually through the respiratory system. It has low pathogenicity, and only a small percentage of infected people show signs of the disease. Although infected, most of the population do not develop the disease. Upon entering the body, the bacilli will migrate to the neural network and enter Schwann cells. Bacteria can also be found in macrophages, muscle cells, and endothelial cells of the blood vessels. After entering Schwann/macrophage cells, the fate of the bacteria depends on the resistance of the infected individual to the infecting organism. Bacilli began to proliferate slowly (about 12–14 days for one bacteria split into two) inside the cell, released from the crushed cell and into the unaffected cells. Until this stage, people remain free from signs and symptoms of leprosy. When bacilli proliferate, the bacterial load increases in the body, and the infection is recognized by the immunological system. Lymphocytes and histiocytes (macrophages) invade infected tissue. At this stage, clinical manifestations may appear as nerve involvement with impaired sensation or skin patches. If not diagnosed and treated in the early stages, further progression

of the disease is determined by the strength of the patient's immune response [14].

In people with strong cell-mediated immunity (CMI), granuloma formation occurs in skin nerves, and cutaneous nerve is enlarged and damaged. Often only a few infiltrated nerves are inflamed, but the inflammation inside the epineurium causes compression and destruction of the unmyelinated sensory and autonomous fibers. Myelinated motor fibers are affected last to produce motor damage. Severe inflammation can cause necrosis in the nerve. Clinical manifestations of sensory loss occur when nearly 30% of sensory fibers are destroyed. A good CMI manages to limit disease to nerve Schwann cells that result in pure leprosy. M. leprae can escape from nerves to adjacent skin all the time and causes classic skin lesions. Areas of the skin with relatively higher temperatures such as axilla, groin, perineum, and hairy scalp are usually spared. But in people with immature cell-cell immunity, the bacilli that enter Schwann cells multiply uncontrollably and destroy the nerves. Also, the bacilli released by infected and destroyed cells are swallowed by histiocytes. Histiocytes with bacilli in it become wandering macrophages. Bacilli multiply in this macrophage and run into other tissues through blood,

The modulation of lipid metabolism and reprogramming of mature Schwann cells have been suggested as a mechanism used by M. leprae to spread disease. New markers associated with local disease, dissemination, or occurrence leprosy reaction events include human interferon, CD163, microRNA-21, NOD2, galectin-3, and toll-like receptors. The role of keratinocytes other than macrophages is interesting to understand in the pathogenesis of leprosy. Adaptive

members had a risk of 3.1 [9, 10, 12].

4. Pathogenesis of leprosy

lymph, or tissue fluid [14].

Two successive strategies—the "Global strategy to further reduce leprosy burden and maintain leprosy control activities" (Period of planning stage: 2006–2010) and "Improved global strategy to further reduce the burden of disease due to leprosy" (Period of planning stage: 2011–2015)—maintaining an emphasis on reducing disease burden by focusing on sustainability through integration. They have moved from the target of "elimination" in terms of the prevalence of disease to the target, which emphasizes the decline in the number of new cases with G2D to promote early detection and reduction of transmission [11].

Leprosy has been linked to stigma throughout history [10]. Stigma manifestations, including self-stigma, social exclusion, and discrimination, although now more subtle with less exile, remain a reality for many affected people [12]. To help leprosy services become more responsive to problems surrounding leprosy-related stigma and reduce its impact, it is necessary to understand the stigma from the perspective of affected people and their family members. Also the views of key people in society, such as neighbors, teachers, religious leaders, and health workers, should be considered. The "human face of leprosy" edited by Gokhale and Sohoni in 1999 has emphasized the need for such stories [13].
