Annals of Tropical Medicine & Parasitology
ISSN: 0003-4983 (Print) 1364-8594 (Online) Journal homepage: http://www.tandfonline.com/loi/ypgh19
Leprosy in Kuwait: an epidemiological study of new cases S. Al-Kandari, A. Al-Anezi, R. N. H. Pugh, Fatima Al-Qasaf & S. Al-Abyad To cite this article: S. Al-Kandari, A. Al-Anezi, R. N. H. Pugh, Fatima Al-Qasaf & S. Al-Abyad (1990) Leprosy in Kuwait: an epidemiological study of new cases, Annals of Tropical Medicine & Parasitology, 84:5, 513-522, DOI: 10.1080/00034983.1990.11812503 To link to this article: http://dx.doi.org/10.1080/00034983.1990.11812503
Published online: 15 Nov 2016.
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Citing articles: 5 View citing articles
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Date: 19 August 2017, At: 18:46
Annals ofTropical Medicine and Parasitology, Vol. 84, No.5, 513-522 (1990)
Leprosy in Kuwait: an epidemiological study of new cases BY S. AL-KANDARI, A. AL-ANEZI, R. N. H. PUGH, FATIMA AL-QA.SAF AND S. AL-ABYAD
Infectious Diseases Hospital, P.O. Box 4710, Safat 13048, Kuwait, Arabian Gulf
Downloaded by [Australian Catholic University] at 18:46 19 August 2017
Received 29 January 1990, Accepted I May 1990 The latency of infection in leprosy is long so that new cases may present several years after emigration from endemic areas. This is of concern to the health authorities in Kuwait, since there is a sizeable immigrant population. An epidemiological study of new cases was, therefore, conducted to assess the extent of the leprosy problem. A total ofl21 (99 male, 22 female) consecutive new leprosy patients were diagnosed nationwide over a six-year period ( 1983-1988). Over 95% of the patients were foreign born, emphasi?'ing that the problem in Kuwait is mainly a reflection of immigration patterns. There were 74 cases of Asio-Indian origin, 13 Oriental and 34 Arab (including two Kuwaiti). This represents a respective mean incidence of the disease in Kuwaitis and other nationalities of 0-49 and 18·92 per 100 000 per year. Polar lepromatous (LL) leprosy was the most frequent type in the Arab group (44·1 %) and polar tuberculoid (TT) the most frequent in the Asia-Indian group (37·8%). LL and borderline lepromatous (BL) types ofleprosy were significantly more frequent in patients over 45-yearsold and in females (P < 0·05), contributing to the higher rate ofLL in the Arab cases. The mean lag time from symptoms onset to presentation to doctor was 9·4 (range 0-192) months, with lepromatous cases tending to present later than other types. The longest lag times occurred in Arab women with LL, suggesting that cultural influences may delay presentation ofleprosy. The mean interval from presentation to diagnosis was 4·1 weeks. The mean latency from entry into Kuwait to diagnosis was 44· 7 (range 0-180) months; which stresses the need for physicians to remain vigilant in considering leprosy, especially in any patient with dermatological, neurological or ophthalmic manifestations of disease.
Leprosy is a chronic inflammatory and granulomatous disease caused by Mycobacterium leprae, with a wide clinical spectrum that reflects the degree of cell-mediated immunity (Ridley and Jopling, 1966; Ridley, 1974). Thus, an adequate cellular response in tuberculoid leprosy localizes inflammation associated with scant bacilli to the skin and peripheral nerves. An impaired cellular response in lepromatous leprosy results in multibacillary disease and systemic involvement, with the potential for spread from the upper respiratory tract. Important complications include destructive effects in anaesthetic areas associated with nerve damage, inflammatory eye disease, and deformity of hands and feet. Current estimates indicate that there are between 11 and 12 million cases ofleprosy in the world, which the World Health Organization aims to combat by control programmes adopting its 1982 recommendations on chemotherapy (WHO, 1982). The new regimens have been remarkably successful, but there is still concern that up to 70% of the estimated world total has yet to receive the effective therapy (Anon., 1988). There still remains a large reservoir source of infection in the endemic areas, particularly in subjects with the more contagious lepromatous form ofleprosy. Immigrants from these areas will continue to introduce leprosy into countries where the disease has been controlled. Unfortunately leprosy is often missed by physicians outside endemic areas and may progress undiagnosed for years. This is of detriment to the patient, and also a hazard to the public since leprosy is propagated by man-to-man transmission. A further challenge to health authorities arises from the long incubation period, described as a minimum two to five years in many texts. Studies in immigrants indicate that the incubation period may reach 20 years or more (Barrett-Connor, 1978). Such studies determine the latent period-from the time of entering a developed country to the onset of symptoms. 0003-4983/90/050513+ 10$03.00/0
© 1990 Liverpool School ofTropical Medicine
LEPROSY IN KUWAIT
514
Long latent periods were reported in a study from New York city, which suggested that leprosy can occur as long as five to 40 years after emigration from endemic areas (Levis et al., 1982). This prompted the present study, which aimed to evaluate the status of leprosy in Kuwait and its relation to immigration.
Downloaded by [Australian Catholic University] at 18:46 19 August 2017
PATIENTS AND METHODS All newly-diagnosed cases ofleprosy in Kuwait are notified, and then referred to the Infectious Diseases Hospital for confirmation, evaluation and treatment. Clinical diagnosis ofleprosy is confirmed by skin biopsy and classified according to Ridley and Jopling ( 1966): polar lepromatous (LL), borderline lepromatous (BL), mid-borderline (BB), borderline tuberculoid (BT), polar tuberculoid (TT) and indeterminate (Ind.). The present study comprised all new confirmed cases for the six-year period from January 1983 to December 1988. The hospital records of all patients were supplemented by data forms to include all relevant demographic and epidemiological information, clinical and laboratory findings. The data were coded, tabulated, and analysed with the assistance of the computer and statistical departments of the Ministry of Public Health, Kuwait.
RESULTS There were 121 new cases ofleprosy ( 1983-23; 1984-20; 1985-25; 1986-21; 1987-19, 1988-13). As shown in Table 1, 39% of the cases were LL or BLand 42% were TT or BT leprosy. The overall male to female ratio of 4·5 was not reflected in the polar forms of the disease. Contributing to this imbalance was a high proportion of females (45%) with LL leprosy and a low proportion (14%) with TT leprosy. Asio-Indian cases formed the largest broad ethnic group, followed by Arab cases. Oriental cases were relatively few for meaningful comparison. The 44·1% of Arab cases with LL leprosy was significantly greater when compared to 21·6% in the Asio-Indian group = 2·40; P < 0·02).
(l
TABLE 1
Ethnic origin of the 121 leprosy cases seen at the Infectious Diseases Hospital, Kuwait (January 1983December 1988 Ethnic origin no. ( "'0 ) Type of leprosy* LL BL BB BT TT Ind. Total
No. of cases(%) 34 13 20 13 38 3
(28·1) (10·7) (16·5) (10·7) (31-4) (2·5)
121 (100)
MjF (rate) 24/10 10/3 19/1 10/3 35/3 1/2
(2-4) (3·3) (19·0) (3·3) (11·7) (0·5)
99/22 (4·5)
Oriental
Arab
(21·6) (12·2) (10·8) (14·9) (37·8) (2·7)
3 (23·1) 1 (7·7) 5 (38·5) 1 (7·7) 3 (23·1)
15 (44·1) 3 (8·8) 7 (20·6) 1 (2·9) 7 (20·6) 1 (2·9)
74 ( 100)
13 (100)
34 (100)
Asia-Indian 16 9 8 11 28 2
*LL polar lepromatous, BL borderline lepromatous, BB mid-borderline, BT borderline tuberculoid, TT polar tuberculoid, Ind. indeterminate.
AL-KANDARI ET AL.
515
TABLE2
Nationality, ethnic origin and sex ofpatients with lepromatous ( LL, BL) or other ( BB, B T, TT and Ind.) types of leprosy
Country of origin
No.(%)
Ethnic origin (%)
Leprosy type No.
ISSN: 0003-4983 (Print) 1364-8594 (Online) Journal homepage: http://www.tandfonline.com/loi/ypgh19
Leprosy in Kuwait: an epidemiological study of new cases S. Al-Kandari, A. Al-Anezi, R. N. H. Pugh, Fatima Al-Qasaf & S. Al-Abyad To cite this article: S. Al-Kandari, A. Al-Anezi, R. N. H. Pugh, Fatima Al-Qasaf & S. Al-Abyad (1990) Leprosy in Kuwait: an epidemiological study of new cases, Annals of Tropical Medicine & Parasitology, 84:5, 513-522, DOI: 10.1080/00034983.1990.11812503 To link to this article: http://dx.doi.org/10.1080/00034983.1990.11812503
Published online: 15 Nov 2016.
Submit your article to this journal
View related articles
Citing articles: 5 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ypgh19 Download by: [Australian Catholic University]
Date: 19 August 2017, At: 18:46
Annals ofTropical Medicine and Parasitology, Vol. 84, No.5, 513-522 (1990)
Leprosy in Kuwait: an epidemiological study of new cases BY S. AL-KANDARI, A. AL-ANEZI, R. N. H. PUGH, FATIMA AL-QA.SAF AND S. AL-ABYAD
Infectious Diseases Hospital, P.O. Box 4710, Safat 13048, Kuwait, Arabian Gulf
Downloaded by [Australian Catholic University] at 18:46 19 August 2017
Received 29 January 1990, Accepted I May 1990 The latency of infection in leprosy is long so that new cases may present several years after emigration from endemic areas. This is of concern to the health authorities in Kuwait, since there is a sizeable immigrant population. An epidemiological study of new cases was, therefore, conducted to assess the extent of the leprosy problem. A total ofl21 (99 male, 22 female) consecutive new leprosy patients were diagnosed nationwide over a six-year period ( 1983-1988). Over 95% of the patients were foreign born, emphasi?'ing that the problem in Kuwait is mainly a reflection of immigration patterns. There were 74 cases of Asio-Indian origin, 13 Oriental and 34 Arab (including two Kuwaiti). This represents a respective mean incidence of the disease in Kuwaitis and other nationalities of 0-49 and 18·92 per 100 000 per year. Polar lepromatous (LL) leprosy was the most frequent type in the Arab group (44·1 %) and polar tuberculoid (TT) the most frequent in the Asia-Indian group (37·8%). LL and borderline lepromatous (BL) types ofleprosy were significantly more frequent in patients over 45-yearsold and in females (P < 0·05), contributing to the higher rate ofLL in the Arab cases. The mean lag time from symptoms onset to presentation to doctor was 9·4 (range 0-192) months, with lepromatous cases tending to present later than other types. The longest lag times occurred in Arab women with LL, suggesting that cultural influences may delay presentation ofleprosy. The mean interval from presentation to diagnosis was 4·1 weeks. The mean latency from entry into Kuwait to diagnosis was 44· 7 (range 0-180) months; which stresses the need for physicians to remain vigilant in considering leprosy, especially in any patient with dermatological, neurological or ophthalmic manifestations of disease.
Leprosy is a chronic inflammatory and granulomatous disease caused by Mycobacterium leprae, with a wide clinical spectrum that reflects the degree of cell-mediated immunity (Ridley and Jopling, 1966; Ridley, 1974). Thus, an adequate cellular response in tuberculoid leprosy localizes inflammation associated with scant bacilli to the skin and peripheral nerves. An impaired cellular response in lepromatous leprosy results in multibacillary disease and systemic involvement, with the potential for spread from the upper respiratory tract. Important complications include destructive effects in anaesthetic areas associated with nerve damage, inflammatory eye disease, and deformity of hands and feet. Current estimates indicate that there are between 11 and 12 million cases ofleprosy in the world, which the World Health Organization aims to combat by control programmes adopting its 1982 recommendations on chemotherapy (WHO, 1982). The new regimens have been remarkably successful, but there is still concern that up to 70% of the estimated world total has yet to receive the effective therapy (Anon., 1988). There still remains a large reservoir source of infection in the endemic areas, particularly in subjects with the more contagious lepromatous form ofleprosy. Immigrants from these areas will continue to introduce leprosy into countries where the disease has been controlled. Unfortunately leprosy is often missed by physicians outside endemic areas and may progress undiagnosed for years. This is of detriment to the patient, and also a hazard to the public since leprosy is propagated by man-to-man transmission. A further challenge to health authorities arises from the long incubation period, described as a minimum two to five years in many texts. Studies in immigrants indicate that the incubation period may reach 20 years or more (Barrett-Connor, 1978). Such studies determine the latent period-from the time of entering a developed country to the onset of symptoms. 0003-4983/90/050513+ 10$03.00/0
© 1990 Liverpool School ofTropical Medicine
LEPROSY IN KUWAIT
514
Long latent periods were reported in a study from New York city, which suggested that leprosy can occur as long as five to 40 years after emigration from endemic areas (Levis et al., 1982). This prompted the present study, which aimed to evaluate the status of leprosy in Kuwait and its relation to immigration.
Downloaded by [Australian Catholic University] at 18:46 19 August 2017
PATIENTS AND METHODS All newly-diagnosed cases ofleprosy in Kuwait are notified, and then referred to the Infectious Diseases Hospital for confirmation, evaluation and treatment. Clinical diagnosis ofleprosy is confirmed by skin biopsy and classified according to Ridley and Jopling ( 1966): polar lepromatous (LL), borderline lepromatous (BL), mid-borderline (BB), borderline tuberculoid (BT), polar tuberculoid (TT) and indeterminate (Ind.). The present study comprised all new confirmed cases for the six-year period from January 1983 to December 1988. The hospital records of all patients were supplemented by data forms to include all relevant demographic and epidemiological information, clinical and laboratory findings. The data were coded, tabulated, and analysed with the assistance of the computer and statistical departments of the Ministry of Public Health, Kuwait.
RESULTS There were 121 new cases ofleprosy ( 1983-23; 1984-20; 1985-25; 1986-21; 1987-19, 1988-13). As shown in Table 1, 39% of the cases were LL or BLand 42% were TT or BT leprosy. The overall male to female ratio of 4·5 was not reflected in the polar forms of the disease. Contributing to this imbalance was a high proportion of females (45%) with LL leprosy and a low proportion (14%) with TT leprosy. Asio-Indian cases formed the largest broad ethnic group, followed by Arab cases. Oriental cases were relatively few for meaningful comparison. The 44·1% of Arab cases with LL leprosy was significantly greater when compared to 21·6% in the Asio-Indian group = 2·40; P < 0·02).
(l
TABLE 1
Ethnic origin of the 121 leprosy cases seen at the Infectious Diseases Hospital, Kuwait (January 1983December 1988 Ethnic origin no. ( "'0 ) Type of leprosy* LL BL BB BT TT Ind. Total
No. of cases(%) 34 13 20 13 38 3
(28·1) (10·7) (16·5) (10·7) (31-4) (2·5)
121 (100)
MjF (rate) 24/10 10/3 19/1 10/3 35/3 1/2
(2-4) (3·3) (19·0) (3·3) (11·7) (0·5)
99/22 (4·5)
Oriental
Arab
(21·6) (12·2) (10·8) (14·9) (37·8) (2·7)
3 (23·1) 1 (7·7) 5 (38·5) 1 (7·7) 3 (23·1)
15 (44·1) 3 (8·8) 7 (20·6) 1 (2·9) 7 (20·6) 1 (2·9)
74 ( 100)
13 (100)
34 (100)
Asia-Indian 16 9 8 11 28 2
*LL polar lepromatous, BL borderline lepromatous, BB mid-borderline, BT borderline tuberculoid, TT polar tuberculoid, Ind. indeterminate.
AL-KANDARI ET AL.
515
TABLE2
Nationality, ethnic origin and sex ofpatients with lepromatous ( LL, BL) or other ( BB, B T, TT and Ind.) types of leprosy
Country of origin
No.(%)
Ethnic origin (%)
Leprosy type No.
