Epidemiology International

Volume 3, Issue1 - 2018, Pg. No. 3-5

Peer Reviewed & Open Access Journal

Research Article

A Study of Reversal Reactions in Leprosy

Shyam Shrivastava1, Meenakshi Sidhar2
Dr. Baba Saheb Ambedkar Hospital & Medical College.
1,2

DOI: https://doi.org/10.24321/2455.7048.201805

Abstract
Reversal reactions (RRs) are the leading cause of deformities and disabilities in leprosy. A comprehensive data
on the magnitude of RR is crucial in implementing and evaluating the leprosy control strategy. Therefore,
we had undertaken this study to find out the rate of reversal reaction (RR) and the key features associated
with it, so that a comprehensive strategy could be adopted for their early detection and management.

In this prospective study, all untreated newly diagnosed cases of leprosy that attended a tertiary level
urban hospital from April 2012–March 2017, were examined for RR at the time of diagnoses as well as
during the course of their treatment.

RR was recorded in 13.61% (84/617) of patients, of these 73.80% (62/84) presented in RR at the time of
the first visit (at the time of diagnoses) to the hospital, while the remaining 26.20% (22/84) developed
it during the course of multidrug therapy (MDT). Majority of RR were seen in multi-bacillary (MB) cases
(78/84, 92.85%), in comparison to pauci-bacillary (PB), where it was seen only in 7.15% (6/84). Another
important finding was the declining trend of RR, from 21.15% (22/104) in 2012-13 to 2.34% (3/128) in
2016-17. MB cases and MDT were found to be the two key features associated with reversal reactions.

Although a significant declining trend of RR was recorded in the study, yet they are still prevalent, particularly
in the MB cases, and most of them were detected at the time of the patient’s first visit. Therefore, a strategy
to further augment the public awareness program regarding the features of RR, as well as explaining these
features to patients before starting treatment should be emphasized.

Keywords: Reversal reactions, Type I reactions, Leprosy reactions

Introduction in various studies prompted us to undertake this study

Reversal reactions (RRs), also known as Type 1 reactions,
are the leading cause of deformities and disabilities in
leprosy, which in turn result into stigma and intense socio-
economic discrimination.¹ Reactions are the primary reason
behind the widespread destruction in leprosy; therefore,
recognition and management of RR is a key element in
prevention of deformities under the leprosy control.
Comprehensive data on the magnitude of RR is crucial in
implementing and evaluating the leprosy control strategy.
This along with wide variation in the rate of RR reported
so as to find out exactly what percentage of our patients
experience reversal reactions and the features associated
with it.
Materials and Methods
It was a prospective study undertaken at a Dr. Baba Saheb
Ambedkar Hospital & Medical College, Delhi. wherein all
untreated newly diagnosed cases of leprosy who attended
the hospital from April 2012 to March 2017, were studied
for features of RR at the time of diagnoses as well as during
the period of treatment. So the pauci-bacillary (PB) cases

Corresponding Author: Dr. Meenakshi Sidhar, Dr. Baba Saheb Ambedkar Hospital & Medical College.
E-mail Id: msidhar67@gmail.com
Orcid Id: https://orcid.org/0000-0002-5384-2485
How to cite this article: Shrivastava S, Sidhar M. A Study of Reversal Reactions in Leprosy. Epidem Int 2018; 3(1): 3-5.

Copyright (c) 2018 Epidemiology International (ISSN: 2455-7048)

Shrivastava S et al.
Epidem. Int. 2018; 3(1) 4

were observed for a period of 6–9 months and multi-bacillary (MB) cases for a period of 12–18 months. This was a
clinical study based on WHO classification. Histopathological and bacteriological studies were done only in doubtful
cases. The criteria for labeling a patient as a case of RR included sudden inflammatory changes in the existing skin
patches and emergence of new patches, pain/tenderness with nerve function impairment (NFI). Cases with acute NFI of
less than 6 months duration at the time of diagnoses or cases that developed NFI during treatment were also counted
under reactions. Only new cases that attended the hospital and followed up through the entire treatment period were
included. A total of 617 patients were studied. Amongst these, 522 were MB cases and 95 were PB.

Results
The reaction profiles of RR reactions are presented in Tables 1 and 2. Out of a total of 617 new cases of leprosy, RR
was recorded in 84 cases, giving an overall rate of 13.6%. Most reactions were seen in MB patients (78/84, 92.85%).
A declining trend of RR, from 21.15% (22/104) in 2012-13 to 21.51% (28/130) in 2013-14, 16.66% (19/144) in 2014-
15, 8.51% (12/141) in 2015-16 and 2.34% (3/128) in 2016-17 were observed. RR was recorded in 13.61% (84/617) of
patients, of these 73.80% (62/84) presented in RR at the time of the first visit (at the time of diagnoses) to the hospital,
while the remaining 26.20% (22/84) developed it during the course of MDT.
Table 1.Number of Cases of Reversal Reactions (RRs) amongst Newly Registered Leprosy Cases
Year No. of No. of No. of No. of Total No. No. of RR Cases No. of RR Cases
PB Cases RR Cases MB Cases RR Cases of Cases amongst of MB amongst
Registered amongst Registered amongst Registered Total No. of New Total No. of RRs
PB Cases MB Cases (PB+MB) Cases (PB+MB) Cases (PB+MB)
with % with %
2012-13 13 0 91 22 104 22 (21.15%) 22 (100%)
2013-14 03 1 127 27 130 28 (21.5%) 27 (96.4%)
2014-15 17 4 97 15 114 19 (16.66) 15 (78.94%)
2015-16 28 1 113 11 141 12 (8.51%) 11 (91.66%
2016-17 34 0 94 3 128 3 (2.34%) 3 (100%
2012–17 95 06 522 78 617 84 (13.61%) 78 (92.85%)
Table 2.Reversal Reactions before and after Treatment
Year Total No. of New Total No. of Cases of RR No. of Cases of RR before No. of Cases of RR after
Cases amongst New Cases Treatment with % Treatment with %
2012-13 104 22 17 (77.27%) 5 (22.72%)
2013-14 130 28 23 (82.14%) 5 (17.86%)
2014-15 114 19 14 (73.67%) 5 (26.31%)
2015-16 141 12 7 (58.33%) 5 (41.66%)
2016-17 128 3 1 (33.33%) 2 (66.66%)
2012-17 617 84 62 (73.80%) 22 (26.19%)

Discussion different time frame involved in the studies. In a large-scale

The published data on the prevalence rate of RR and nerve
function impairment (NFI), reported in various studies,
showed wide variations, ranging from 3.5% amongst PB
cases in Malawi to 47.5% amongst MB cases in Zaire.²
The lowest prevalent rate of 9.6% amongst MB cases was
recorded in an Indonesian study.³ In an INFIR⁴ cohort study,
38% of a cohort of a newly diagnosed MB leprosy patients
had recent or new reactions or nerve damage at the time
of diagnosis. The ILEP Learning Guide II, 2002 mentioned
that about a quarter of all people with leprosy were likely
to get a Type 1 reaction.5 The wide variations in the rate
of RR in these various studies indicate the different case
definitions, different classifications, different locations and
cohort study (BANDS)6 of 24 months follow up, acute NFI
was found in 36% of MB cases and 4.4% of PB cases. In the
same study, Type 1 reactions without NFI were recorded
in 49 out of 357 (13%) MB cases and 13 of 2153 (0.6%)
PB cases. Another 15-year retrospective study by Kumar
et al.7 from India reported that a total of 33% (858/2600)
patients developed RR at some point of time.
An overall RR rate of 13.61% (84/617), recorded in the
present study, came close to 16.5% (98/594) recorded in
a prospective cohort study from Ethiopia (AMFES),8 and
12.9% recorded in a study from Hyderabad, India.9
RRs have been documented to be associated with several

ISSN: 2455-7048
DOI: https://doi.org/10.24321/2455.7048.201805

5 Epidem. Int. 2018; 3(1)
risk factors like treatment with bactericidal drugs, extensive
disease, borderline cases, after BCG vaccination facial
patches, and positive bacteriological index.5-9 Among these,
extensive disease (MB cases) and the bactericidal drugs
(MDT) are the two most common and widely acknowledged
risk factors. MB cases and MDT have also been found to
be the major risk factors associated with RR in the present
study as approximately 92.85% (78/84) of RRs were seen in
MB cases and 26.20% (22/84) of RRs were observed after
starting MDT. The lower rate of RR recorded in the present
study appears to be due to declining prevalence of highly
bacillated cases, as a result of effective implementation
of leprosy elimination program. Although sustaining the
effective leprosy control strategy will further reduce the
prevalence of RR, yet it is mandatory on the part of the
treating physician to explain in details the features of RR
to the patient before starting treatment so they could be
identified and reported without delay.
Conclusion
A significant decline in the RR from 2012-13 to 2016-17
was observed, which points to an effective leprosy control
program. But these reactions are still prevalent. MB cases
and MDT were found to be the two key features associated
with reversal reactions. These findings emphasize the
need to further augment the public awareness program
regarding the features of RR,
Conflict of Interest: None
References
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Shrivastava S et al.
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Date of Submission: 2018-03-17
Date of Acceptance: 2018-04-17
ISSN: 2455-7048
DOI: https://doi.org/10.24321/2455.7048.201805