Abstract
An observational pilot study was conducted to assess the nutritional status and morbidity profile of childhood contacts of leprosy in an endemic area (Chengalpattu) in India. A total of 70 such children were included in the study. Sociodemographic data were collected using a one-to-one interview method and the children were evaluated by dermatologists qualified in paediatric leprosy. The obtained data were computed. Three children were diagnosed to have leprosy through this study. Nutritional status assessment in these children demonstrated malnutrition, a common finding. Regular contact screening of children in endemic areas for early case detection, disability prevention and thereby prevention of community transmission is mandatory. Further research is needed concerning the role of malnutrition in children and its relation to morbidity in leprosy. The closeness and duration of contact of leprosy is also an important risk factor. Effective strategies to diagnose subclinical infection are needed.
Introduction
Leprosy is a public health problem in many low- and middle-income countries. It predominantly affects the skin and peripheral nerves. Childhood leprosy reflects the extent of disease transmission in the community. 1 India is a major contributor of the global leprosy case load. A household contact is the main risk factor. Early detection is emphasised by all healthcare professionals; therefore, active contact screening is an efficient tool to reduce the burden of leprosy. 2
Leprosy has been eliminated (i.e. prevalence < 1:10,000 people) from most countries, according to the World Health Organization (WHO). India officially achieved elimination in December 2005, but children comprise approximately 10% of new cases detected. This shows there is still active transmission of M. leprae among certain Indian communities and this may thus build endemicity. 3 The prevalence of previously undiagnosed leprosy in the general population, in a highly endemic area, is six times higher than the registered prevalence. 4 Early diagnosis of leprosy is essential to prevent deformities, whose consequences are more catastrophic in children aged <15 years, 5 as the effect on occupation may have adverse economic effects. 6 The various risk factors associated with leprosy and their contacts are still not clearly known. Examination of factors at a group level and an individual level is important. The aim of our study was to assess the possible risk factors for the development of disease from a leprosy contact. 7
The effect of nutritional status of children has not been much studied. We looked not only at their nutritional status but also the prevalence of leprosy and subclinical infections.
Methods
Ours was an observational pilot study conducted for two months between August and September 2017, analysing 70 rural children aged <15 years living with a household contact of leprosy. There was no predetermined sample size. A previously diagnosed case of leprosy living together with family members and sharing the same roof and meals from a common kitchen defined a household contact. Children already diagnosed with leprosy were excluded.
Cases recorded in the Central Leprosy Teaching and Research Institute (CLTRI) at Chengalpattu, Kancheepuram district, Tamil Nadu state in India, who had children living with them in their homes, in the rural areas surrounding the institute, were selected. This is a representative sample of people settled in an area close to CLTRI, living, for more than two decades, in a colony of mixed cultures of people from different religious and linguistic backgrounds of south India.
We studied 100 households, of which 72 had 380 household contacts. A total of 45 households had children aged <15 years; 70 of these children were selected for the study. Informed written consent, briefing about leprosy and the main objectives of our study, was obtained from the parents, or another responsible adult accompanying them, of those who agreed to take part in the study.
A one-to-one interview method was employed to collect information regarding demographic characteristics, socioeconomic factors, environmental conditions, feeding practices, food habits and any present or recent health problems. Special emphasis was given to immunisation status, as the tuberculosis and leprosy bacilli are related. Anthropometric measurements were taken, following standard procedures according to guidelines. 8 The mean value of body mass index (BMI) at different ages was compared with the corresponding reference values of the National Health and Statistics Report. 9
A detailed general clinical examination was carried out in every child by a dermatologist qualified in paediatric leprosy; girls were assessed by a female examiner. Any suspicious skin lesions were noted and further testing was carried out. Nerve function was assessed by voluntary muscle testing (VMT) for motor function and was graded as strong (S), weak (W) or absent (P), the latter two being recorded as motor nerve function impairment (NFI). Any visible lesion on hands and feet or any other impairment was also noted. Ocular function was tested by noting present (Pre) or absent (Abs) eyelid gap (in mm) and visual acuity (using Snellen's chart for each eye separately at a distance of 6 m). A WHO disability classification was calculated for eyes, hands and feet (EHF) (in the range of 0–12). 10
If any skin lesion with sensory loss was present, the case was classified as indeterminate; when there was only a hypopigmented macule, with no detection of nerve involvement as paucibacillary (PB), any of the clinical forms defined by the Ridley–Jopling classification were defined as such. 11 Slit skin smears for acid-fast bacilli were performed in all children with suspicious skin lesions. 12
Results
The children's age distribution is given in Figure 1. Anthropometric data are shown in Figures 2 and 3. Weight for height data of the 10 (14%) children aged <5 years are represented in Figure 4. Weight for age data of the 26 (37%) children aged <10 years are given in Figure 5. BMI for age correlated with WHO growth standards was plotted in Figure 6. Head circumference is shown in Figure 7. Socioeconomic status measured according to the modified Kuppuswamy scale is shown in Figure 8 and household characteristics are shown in Figure 9. Forty children lived in overcrowded conditions as defined by Park.
13
Age distribution. Height for age – boys. Height for age – girls. Weight for height (0–5 years). Weight for age (0–10 years). Body mass index for age. Head circumference (0–5 years). Socioeconomic status. Household features.
A total of 64 (91%) children were completely immunised at survey; 61 (87%) were breastfed immediately after birth, six within a few hours, but three not at all. Other information regarding feeding practices are shown in Table 1. Food cravings or most preferred foods are shown in Figure 10.
Food craving and food avoidance. Feeding practices.
Present or previous co-morbidities.
Details of children diagnosed with leprosy.
Discussion
The majority of the 70 children were aged 10–15 years, with all three diagnosed cases of leprosy falling in this age group. After analysing all the anthropometric factors, it was found that girls had better anthropometric measurements compared to boys. This can be substantiated based on Z scores in WHO growth standards. 14
We found out that 3%–48% of these children were malnourished, irrespective of the type of malnutrition. None were overweight or obese.
Many children living in overcrowded semi-pucca houses and drinking untreated drinking water are likely to have exanthematous illness; this will explain the 30% of children having such illnesses. Most of these children washed their hands regularly, implying good personal hygiene.
We found that exclusive breastfeeding for six months and the introduction of complementary feeds then are important factors to prevent malnutrition and infection in children. From the data collected, it can be implied that approximately 30–35 children were malnourished; 30 were exclusively breastfed for <6 months. 15
The presence of pallor is a fairly reliable indicator of anaemia. The WHO estimates that 25% of pre-schoolers and 40% of school-going children are, in fact, truly anaemic. All 19 children with pallor were school-goers. They made up 27% of the study population. This is less than the WHO estimate. 16
According to the National Leprosy Eradication Programme Annual Report 2015–2016, children made up 8.94% of new cases detected throughout the country during 2015–2016. The rate of child cases in Tamil Nadu was 15.86%, of which 1.5% were multibacillary and 14.36% paucibacillary cases. There was one new child with Grade 2 disability in Tamil Nadu. 17
Among our study population, 3 (4.28%) children were diagnosed with leprosy, which signifies a high prevalence in Chengalpattu, as all were leprosy contacts. Two had multibacillary while one had paucibacillary leprosy. 18 All three were classified as cases of borderline tuberculoid (BT) leprosy according to the Ridley–Jopling classification. 19 As accurate statistical data relating to the numbers of children aged <15 year in Chengalpattu are unavailable, the detection rate in new child cases could not be calculated.
All three children were leprosy contacts for 10 years or more, before diagnosis was confirmed. The average incubation period for M. leprae is five years but may be in the range of 1–20 years, 20 thus confirming the importance of closeness and duration of contact.
Child 1, who had been incompletely immunised, was known to have a ventricular septal defect. Of the three children, 2 (66.6%) were malnourished, supporting the presumption that malnutrition is a risk factor in contacts.
Conclusion
We believe it desirable to substantiate an association between nutritional factors and the risk of developing leprosy among child household contacts of leprosy. Incomplete immunisation is likely to contribute to morbidity. Regular contact screening and early case detection are essential to prevent further transmission in endemic areas. Closeness and duration of contact to leprosy are particularly important risk factors. Detecting subclinical infection needs further research.
Our study cannot reflect the whole population, but stronger surveillance of child leprosy contacts should be a mandatory part of leprosy control programmes.
Footnotes
Acknowledgement
The authors thank ICMR, Delhi, India for approving this research through the Short Term Studentship (STS)-2017, under which the study was carried out.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received the following financial support for the research, authorship, and/or publication of this article: ICMR provided a stipend of INR 10,000 for the research.
