Barriers to prevent disability due to leprosy in children are breachable

The new World Health Organization Leprosy Strategy 2016-2020 has as a goal the earlier detection of childhood leprosy in order to prevent disabling nerve damage. In this volume of The Journal, providers from the dermatology referral unit in Para-State, the Amazon region in the northern part of Brazil that has the highest rate of leprosy in children, provide uncommon insight into disease epidemiology, manifestations, and risk factors for nerve damage.

A total of 45 children <15 years of age were newly diagnosed (among 403 cases, 11%) during 15 months in 2014-2015, 41 of whom were recruited to a structured dermatologic/neurologic examination and an interview seeking information on sociodemographic, clinical, and epidemiologic data. For the majority of children, referral to the unit was the mode of diagnosis, symptom onset was >1 year before diagnosis, and almost one-half of patients had seen ≥3 physicians before diagnosis (and frequently were given incorrect diagnoses). Statistically significant associations (with odds ratios from 6 to 19) for nerve damage at diagnosis were: >5 skin lesions, lesions along the path of nerve trunks (Figure A), number of doctors seen, and rare or no visits from community health workers. Additionally, they identified missed opportunities for prevention as one-half of patients had previous contact with individuals (the majority within the household) known to have leprosy yet only one participant had 2 Bacillus Calmette-Guérin vaccine scars. Recommended management for asymptomatic contacts upon diagnosis of leprosy in Brazil is a booster dose of Bacillus Calmette-Guérin for those ≥1 year of age.

The authors identify barriers to optimal outcome of affected children as difficulty in diagnosing leprosy in children, lack of community health workers who can monitor for signs of leprosy, lack of primary doctor's knowledge of manifestations, and knowledge of referral units (or doubts about their role). Because only 7% of children had primary neural leprosy, urgency to recognize and treat patients prior to disabling nerve damage is possible and is a powerful mandate for change.