Primary care quality and its effects on leprosy monitoring indicators.

OBJECTIVES: to evaluate the quality of primary care in leprosy control actions, to correlate effects on monitoring indicators. METHODS: a cross-sectional study, conducted in Belo Horizonte, from July to September 2014. Interviews with 408 professionals were conducted through the application of a tool that assesses attributes of primary care in leprosy control actions, and monitoring indicators were calculated. Spearman correlation was used, significance level p < 0.05. RESULTS: the overall score correlated with the percentage of cases treated in primary care and of family health staff coverage. The derived score correlated with the percentage of cases treated in primary care, and the essential score correlated with the proportion and rate of cases diagnosed, with grade 2 physical disability. CONCLUSIONS: the quality of leprosy control actions performed by primary care professionals produces impacts on health indicators, and developing strategies consistent with the reality of the territory is necessary.

[Orientation of primary care in actions to control leprosy: factors relating to professionals]. / Orientación de la atención primaria en las acciones contra la lepra: factores relacionados con los profesionales.

OBJECTIVE: To identify factors of professionals that relate to the degree of primary health care orientation in the control of leprosy. METHOD: Study carried out in 70 units of Family Health Strategy of a capital of Brazil, between July and September 2014. An evaluation instrument applied to 408 health professionals was used. The multiple linear regression-bootstrap model was applied to analyze the association of the general, essential and derived score with the explanatory factors of the professionals (work time in the unit and in primary care services, control actions, case care and leprosy training). RESULTS: In the descriptive analysis most of the professionals did not attend cases and did not receive training to perform leprosy actions. A strong orientation was observed in the essential and general score of primary care and the association with leprosy education. In the derived score, weak orientation and association were observed with training in the disease for doctors and community health agents. CONCLUSION: Professional experience in the Family Health Strategy and leprosy care is crucial for the service to be a provider of control actions oriented according to the essential and derived attributes of primary health care. Brazil has made progress in reducing the incidence of leprosy; however, it is necessary to increase the effectiveness of health surveillance, as a means of early detection and training of professionals.

Relação da hanseníase com a cobertura da estratégia saúde da família e condições socioeconómicas / Relationship of leprosy with coverage of family health strategy and socioeconomic conditions / Relación de la lepra con la cobertura de la estrategia de salud familiar y condiciones socioeconómicas

RESUMO Objetivo: Analisar a epidemiologia da hanseníase e sua relação com a cobertura da Estratégia Saúde da Família e as condições socioeconômicas na Paraíba, Brasil, no período de 2001 a 2016. Material e Método: Estudo ecológico de abordagem quantitativa. Os dados secundários foram extraídos do Sistema de Informação de Agravos de Notificação. Verificou-se a relação dos indicadores epidemiológicos da hanseníase com a cobertura da Estratégia de Saúde da Família e Índice de Desenvolvimento Humano Municipal por meio da regressão de Poisson com inflação de zeros. Resultados: Foram analisados 12.134 casos novos de hanseníase. O aumento da cobertura da Estratégia de Saúde da Família contribuiu significativamente para incremento na taxa de detecção na população geral. A melhora do Índice de Desenvolvimento Humano Municipal contribuiu para aumento de casos da doença na população geral e redução em menores de 15 anos. Conclusão: Houve melhoria dos indicadores epidemiológicos da doença mediante implantação de serviços de saúde e avanços nos indicadores sociais; no entanto, ainda persistem situações de pobreza e desigualdade que contribuem para a continuidade da hanseníase. Reforça-se a importância de investimentos nas ações de saúde e políticas inclusivas, com vistas a minimizar as iniquidades existentes e controlar a endemia.

ABSTRACT Objective: To analyze the epidemiology of leprosy and its relationship with the coverage of the Family Health Strategy and the socioeconomic conditions in Paraíba, Brazil, from 2001 to 2016. Material and Method: Ecological study with a quantitative approach. We extracted secondary data from the Notifiable Diseases Information System (SINAN, as per its Portuguese acronym). We checked the relationship of leprosy epidemiological indicators with the coverage of the Family Health Strategy and the Municipal Human Development Index by Zero-inflated Poisson regression model. Results: We analyzed a total of 12,134 new leprosy cases. The increased coverage of the Family Health Strategy contributed significantly to the increment in the detection rate in the general population. The improvement of the Municipal Human Development Index contributed to the increased number of cases of the disease in the general population and decrease in people under the age of 15. Conclusion: There was an improvement in the epidemiological indicators of the disease through the implementation of health services and advances in social indicators; however, there are still situations of poverty and inequality that contribute to the continuity of leprosy. We should emphasize the importance of investments in health actions and inclusive policies, with a view to minimizing the existing inequities and controlling this endemic.

RESUMEN Objetivo: Analizar la epidemiología de la lepra y su relación con la cobertura de la Estrategia de Salud Familiar y las condiciones socioeconómicas en Paraíba, Brasil, entre 2001 y 2016. Material y Método: Estudio ecológico con enfoque cuantitativo. Los datos secundarios se extrajeron del Sistema de Información de Enfermedades de Declaración Obligatoria (SINAN, según su sigla en portugués). Se verificó la relación entre los indicadores epidemiológicos de la lepra con la cobertura de la Estrategia de Salud Familiar y el Índice de Desarrollo Humano Municipal mediante la regresión de Poisson con inflación de ceros. Resultados: Se analizaron un total de 12.134 casos nuevos de lepra. El crecimiento de la cobertura de la Estrategia de Salud Familiar contribuyó significativamente al incremento de la tasa de detección en la población general. La mejora del Índice de Desarrollo Humano Municipal contribuyó al crecimiento de casos de la enfermedad en la población general y la reducción en personas menores de 15 años. Conclusión: Hubo una mejora en los indicadores epidemiológicos de la enfermedad mediante la implementación de servicios de salud y avances en los indicadores sociales, sin embargo, aún existen situaciones de pobreza y desigualdad que contribuyen a la continuidad de la lepra. Se refuerza la importancia de inversiones en acciones de salud y políticas inclusivas, con miras a mitigar las disparidades existentes y controlar esta endemia.

[Leprosy trends following implementation of an intervention project in a state capital in the North of Brazil, 2002-2016]. / Tendências da hanseníase após implementação de um projeto de intervenção em uma capital da Região Norte do Brasil, 2002-2016.

The project Palmas Free of Leprosy was implemented to improve indicators and deal with the disease, since the capital of Tocantins State is the most hyperendemic state capital in Brazil. This study measures the impact of the project's intervention through trend analysis of the priority indicators in Palmas, from 2002 to 2016. The study was based on an analysis of data from the Brazilian Information System for Notifiable Diseases (SINAN) and reports of applied training courses with problem-solving methodology. The indicators for new leprosy cases in Palmas residents were investigated, and the trends were identified by joinpoint regression analysis to assess the results. In the year the intervention project was implemented (2016), the detection rate for new cases in the overall population was 236.3/100,000 inhabitants, and this indicator showed a significant decrease of -7.5% from 2002 to 2014. From 2014 to 2016, there was a significant increase of 104.6% in overall detection. The detection rate in individuals under 15 years of age also showed a reduction of -4.6%, but in the years 2014, 2015, and 2016 there was an increase of 111.1%, together with detection rates for grades 0, 1, and 2, with 59.3%, 225.2%, and 121.7%, respectively. The proportion of cases detected by contact assessment showed a significant increase of 201.1% from 2014 to 2016. The data proved the effectiveness and potentiality of the project's intervention strategy for the diagnosis and control of leprosy in Palmas. The study provided evidence that timely diagnosis by primary care services results in indicators that reflect the real incidence of cases.

O projeto Palmas Livre da Hanseníase foi implementado para o incremento dos indicadores e o enfrentamento da doença, visto que a capital do Tocantins é a mais hiperendêmica do país. Este estudo mede o impacto da intervenção do projeto por meio da análise da tendência de indicadores prioritários em Palmas, 2002-2016. Baseia-se em análise de dados advindos do Sistema de Informação de Agravos de Notificação (SINAN) e de relatórios de capacitações aplicadas com metodologia de problematização. Os indicadores dos casos novos de hanseníase residentes em Palmas foram investigados, e suas tendências foram identificadas por análise de regressão joinpoint para avaliação dos resultados. No ano de implementação do projeto de intervenção (2016), o coeficiente de detecção de casos novos na população geral foi de 236,3/100 mil habitantes, e esse indicador apresentava decréscimo significativo de -7,5% no período de 2002 a 2014. Nos anos entre 2014 e 2016, houve aumento significativo de 104,6% para a detecção geral. O coeficiente de detecção em menores de 15 anos também apresentava queda de -4,6%, mas nos anos de 2014, 2015 e 2016, houve aumento de 111,1%, juntamente com os coeficientes de detecção de casos com grau 0, 1 e 2, com 59,3%, 225,2% e 121,7%, respectivamente. A proporção de casos detectados por avaliação de contatos teve acréscimo significativo de 201,1% no período de 2014 a 2016. Os dados comprovaram a efetividade e potencialidade da estratégia de intervenção do projeto para as ações de diagnóstico e controle da hanseníase em Palmas. Trouxe evidências de que a agilidade diagnóstica dos serviços de atenção primária resulta em indicadores que refletem a incidência real de casos.

El proyecto Palmas Libre de Hanseniasis se implementó para el incremento de indicadores y combate a la enfermedad, dado que la capital de Tocantins es la más hiperendémica de Brasil. Este estudio mide el impacto de la intervención del proyecto, mediante el análisis de la tendencia de indicadores prioritarios en Palmas, 2002-2016. Se basa en un análisis de datos procedentes del Sistema de Información sobre Enfermedades de Notificación Obligatoria (SINAN por sus siglas en portugués) y de informes de capacitaciones, aplicadas con metodología de problematización. Se investigaron los indicadores de casos nuevos de hanseniasis, en residentes de Palmas, y se identificaron sus tendencias mediante análisis de regresión joinpoint para la evaluación de los resultados. En el año de implementación del proyecto de intervención (2016), el coeficiente de detección de casos nuevos en la población general fue de 236,3/100 mil habitantes, y ese indicador presentaba una disminución significativa de un -7,5%, durante el período de 2002 a 2014. Entre los años de 2014 a 2016, hubo un aumento significativo de un 104,6% en la detección general. El coeficiente de detección en menores de 15 años también presentaba una bajada de -4,6%, pero durante los años de 2014, 2015 y 2016, hubo un aumento de 111,1%, junto a los coeficientes de detección de casos con grado 0, 1 y 2, con un 59,3%, 225,2% y 121,7%, respectivamente. La proporción de casos detectados por la evaluación de contactos tuvo un aumento significativo de un 201,1%, durante el período de 2014 a 2016. Los datos comprobaron la efectividad y potencialidad de la estrategia de intervención del proyecto para las acciones de diagnóstico y control de la hanseniasis en Palmas. Hubo evidencias de que la agilidad diagnóstica de los servicios de atención primaria se traduce en indicadores que reflejan la incidencia real de casos.

Tendências da hanseníase após implementação de um projeto de intervenção em uma capital da Região Norte do Brasil, 2002-2016 / Leprosy trends following implementation of an intervention project in a state capital in the North of Brazil, 2002-2016 / Tendencias de la hanseniasis tras la implementación de un proyecto de intervención en una capital de la región norte de Brasil, 2002-2016

Resumo: O projeto Palmas Livre da Hanseníase foi implementado para o incremento dos indicadores e o enfrentamento da doença, visto que a capital do Tocantins é a mais hiperendêmica do país. Este estudo mede o impacto da intervenção do projeto por meio da análise da tendência de indicadores prioritários em Palmas, 2002-2016. Baseia-se em análise de dados advindos do Sistema de Informação de Agravos de Notificação (SINAN) e de relatórios de capacitações aplicadas com metodologia de problematização. Os indicadores dos casos novos de hanseníase residentes em Palmas foram investigados, e suas tendências foram identificadas por análise de regressão joinpoint para avaliação dos resultados. No ano de implementação do projeto de intervenção (2016), o coeficiente de detecção de casos novos na população geral foi de 236,3/100 mil habitantes, e esse indicador apresentava decréscimo significativo de -7,5% no período de 2002 a 2014. Nos anos entre 2014 e 2016, houve aumento significativo de 104,6% para a detecção geral. O coeficiente de detecção em menores de 15 anos também apresentava queda de -4,6%, mas nos anos de 2014, 2015 e 2016, houve aumento de 111,1%, juntamente com os coeficientes de detecção de casos com grau 0, 1 e 2, com 59,3%, 225,2% e 121,7%, respectivamente. A proporção de casos detectados por avaliação de contatos teve acréscimo significativo de 201,1% no período de 2014 a 2016. Os dados comprovaram a efetividade e potencialidade da estratégia de intervenção do projeto para as ações de diagnóstico e controle da hanseníase em Palmas. Trouxe evidências de que a agilidade diagnóstica dos serviços de atenção primária resulta em indicadores que refletem a incidência real de casos.

Abstract: The project Palmas Free of Leprosy was implemented to improve indicators and deal with the disease, since the capital of Tocantins State is the most hyperendemic state capital in Brazil. This study measures the impact of the project's intervention through trend analysis of the priority indicators in Palmas, from 2002 to 2016. The study was based on an analysis of data from the Brazilian Information System for Notifiable Diseases (SINAN) and reports of applied training courses with problem-solving methodology. The indicators for new leprosy cases in Palmas residents were investigated, and the trends were identified by joinpoint regression analysis to assess the results. In the year the intervention project was implemented (2016), the detection rate for new cases in the overall population was 236.3/100,000 inhabitants, and this indicator showed a significant decrease of -7.5% from 2002 to 2014. From 2014 to 2016, there was a significant increase of 104.6% in overall detection. The detection rate in individuals under 15 years of age also showed a reduction of -4.6%, but in the years 2014, 2015, and 2016 there was an increase of 111.1%, together with detection rates for grades 0, 1, and 2, with 59.3%, 225.2%, and 121.7%, respectively. The proportion of cases detected by contact assessment showed a significant increase of 201.1% from 2014 to 2016. The data proved the effectiveness and potentiality of the project's intervention strategy for the diagnosis and control of leprosy in Palmas. The study provided evidence that timely diagnosis by primary care services results in indicators that reflect the real incidence of cases.

Resumen: El proyecto Palmas Libre de Hanseniasis se implementó para el incremento de indicadores y combate a la enfermedad, dado que la capital de Tocantins es la más hiperendémica de Brasil. Este estudio mide el impacto de la intervención del proyecto, mediante el análisis de la tendencia de indicadores prioritarios en Palmas, 2002-2016. Se basa en un análisis de datos procedentes del Sistema de Información sobre Enfermedades de Notificación Obligatoria (SINAN por sus siglas en portugués) y de informes de capacitaciones, aplicadas con metodología de problematización. Se investigaron los indicadores de casos nuevos de hanseniasis, en residentes de Palmas, y se identificaron sus tendencias mediante análisis de regresión joinpoint para la evaluación de los resultados. En el año de implementación del proyecto de intervención (2016), el coeficiente de detección de casos nuevos en la población general fue de 236,3/100 mil habitantes, y ese indicador presentaba una disminución significativa de un -7,5%, durante el período de 2002 a 2014. Entre los años de 2014 a 2016, hubo un aumento significativo de un 104,6% en la detección general. El coeficiente de detección en menores de 15 años también presentaba una bajada de -4,6%, pero durante los años de 2014, 2015 y 2016, hubo un aumento de 111,1%, junto a los coeficientes de detección de casos con grado 0, 1 y 2, con un 59,3%, 225,2% y 121,7%, respectivamente. La proporción de casos detectados por la evaluación de contactos tuvo un aumento significativo de un 201,1%, durante el período de 2014 a 2016. Los datos comprobaron la efectividad y potencialidad de la estrategia de intervención del proyecto para las acciones de diagnóstico y control de la hanseniasis en Palmas. Hubo evidencias de que la agilidad diagnóstica de los servicios de atención primaria se traduce en indicadores que reflejan la incidencia real de casos.

Reactional state and nutritional profile among leprosy patients in the primary health care system, Greater Vitória, Espírito Santo State, Brazil.

Leprosy may present acute/subacute inflammatory processes (leprosy reactions). The study characterized the reactional states of patients at health clinics in Vitória, Espírito Santo State, Brazil, and associated them with sociodemographic factors and clinical/nutritional variables. between January and December 2009, longitudinal follow-up of patients with leprosy continued until leprosy reactions occurred or patients completed 6 months of multidrug therapy. Of the 151 patients participating, 78 (51.7%) were females, 48 (31.8%) had 5 to 8 years schooling, 93 (61.6%) worked and earned from 1 to 3 minimum wages, and 55 (36.4 %) had leprosy reactions, but with no statistical association to socioeconomic characteristics or nutritional status. However, absence of reaction was more common in the low-weight group, suggesting a trend in this group to protection from the reaction (p = 0.0906). The study found no association between nutritional status and leprosy reaction.

Reactional state and nutritional profile among leprosy patients in the primary health care system, Greater Vitória, Espírito Santo State, Brazil / Estado reacional e perfil nutricional em portadores de hanseníase acompanhados na rede de atenção primária à saúde da Grande Vitória, Espírito Santo, Brasil

Leprosy may present acute/subacute inflammatory processes (leprosy reactions). The study characterized the reactional states of patients at health clinics in Vitória, Espírito Santo State, Brazil, and associated them with sociodemographic factors and clinical/nutritional variables. between January and December 2009, longitudinal follow-up of patients with leprosy continued until leprosy reactions occurred or patients completed 6 months of multidrug therapy. Of the 151 patients participating, 78 (51.7 percent) were females, 48 (31.8 percent) had 5 to 8 years schooling, 93 (61.6 percent) worked and earned from 1 to 3 minimum wages, and 55 (36.4 percent) had leprosy reactions, but with no statistical association to socioeconomic characteristics or nutritional status. However, absence of reaction was more common in the low-weight group, suggesting a trend in this group to protection from the reaction (p = 0.0906). The study found no association between nutritional status and leprosy reaction.

A hanseníase pode apresentar processos inflamatórios agudos/subagudos (reações hansênicas). Os objetivos foram caracterizar os estados reacionais de pacientes de Unidades de Saúde da Grande Vitória (Espírito Santo, Brasil) e associá-los aos fatores sociodemográficos e a variáveis clínicas/nutricionais. Estudo longitudinal, de monitoramento de portadores de hanseníase acompanhados até o aparecimento da reação hansênica ou até 6 meses iniciais da poliquimioterapia, de janeiro a dezembro de 2009. Participaram 151 pacientes, sendo 78 (51,7 por cento) femininos; 48 (31,8 por cento) estudaram de cinco a oito anos; 93 (61,6 por cento) trabalhavam e ganhavam de um a três salários mínimos; 55 (36,4 por cento) apresentaram reação hansênica, sem associação estatística às características socioeconômicas nem ao estado nutricional. Porém, a ausência de reação foi maior no grupo baixo peso, sugerindo neste grupo tendência na proteção da reação (p = 0,0906). No estudo não houve associação do estado nutricional com a reação hansênica.

Perfil epidemiológico da hanseníase na microrregião de araçuaí e sua relação com ações de controle / Epidemiological profile of leprosy at the microregion of araçuaí and its relation with actions control

A hanseníase representa um problema de saúde pública no Brasil pelos altos índices de prevalência e incidência. O objetivo deste estudo é analisar a situação epidemiológica da hanseníase e sua relação com o desenvolvimento das ações de controle na microrregião de Araçuaí. Trata-se de estudo epidemiológico, descritivo, cujos dados foram coletados das fichas de notificação de casos de hanseníase de municípios da microrregião, período 1998-2007, disponibilizados no Sistema de Informação de Agravos de Notificação - SINAN. Foram construídos e analisados indicadores epidemiológicos e operacionais preconizados pelo Ministério da Saúde. Foram notificados 343 casos, resultando em uma detecção geral média de 28,5 casos/100.000 habitantes/ano. A proporção de casos detectados com grau II de incapacidade e o predomínio de formas passivas de detecção sugerem diagnóstico tardio e corroboram a importância da integração das ações de controle da hanseníase na atenção básica.

Recurrence of leprosy cases in the State of Mato Grosso, Central-West Brazil.

OBJECTIVE: To compare new registrations of recurrences of leprosy cases in primary healthcare units (PHUs) and in specialized units in the State of Mato Grosso. METHODS: This was a cross-sectional study based on all new registrations (N = 323) of recurrences of leprosy cases within the Notifiable Disease Information System (SINAN) between 2004 and 2006 that were made in the State of Mato Grosso, Central-West Brazil. The cases diagnosed were compared regarding sex, age, clinical-laboratory characteristics and geographical distribution among the municipalities. To compare and calculate the proportions of the variables, the chi-square test at the significance level of 5% was used. RESULTS: Among the new registrations of recurrences, 20% were confirmed at specialized units and 80% at PHUs. However, most of the diagnoses at PHUs presented negative bacilloscopy findings (c2 = 12.34; p = 0.002). Seventy-one per cent of the cases were among males; the mean age was 43 years. No differences in the percentages of registrations were observed between the healthcare units with regard to clinical form, operational classification or degree of physical incapacity. Out of the total number of municipalities in the state, 64.7% presented recurrences and these accounted for 6 to 20% of all registrations. CONCLUSIONS: The new registrations of cases of recurrence in Mato Grosso were influenced by the diagnoses made at PHUs, thus suggesting that there is a deficiency within the healthcare services in recognizing cases of recurrence.

Recidivas de casos de hanseníase no estado de Mato Grosso / Recurrencia de casos de hanseníasis en el estado de Mato Grosso, Centro-Oeste de Brasil, 2004-2006 / Recurrence of leprosy cases in the State of Mato Grosso, Central-West Brazil

OBJETIVO: Comparar as novas entradas por recidiva de hanseníase em unidades básicas de saúde (UBS) e em unidades especializadas (UE) no estado de Mato Grosso. MÉTODOS: Estudo transversal com base em todos os registros (N = 323) de recidivas de hanseníase do Sistema de Informação de Agravos de Notificação (Sinan) de 2004 a 2006, notificados no estado de Mato Grosso. Os casos diagnosticados foram comparados quanto ao sexo, idade, aspectos clínico-laboratoriais e distribuição geográfica nos municípios. Para a comparação e cálculo das proporções das variáveis utilizou-se o teste qui-quadrado ao nível de significância de 5 por cento. RESULTADOS: Das novas entradas de recidiva, 20 por cento foi confirmado nas UE e 80 por cento em UBS; entretanto, a maioria dos diagnósticos em UBS tinham baciloscopia negativa (÷² =12,34; p = 0,002)...

OBJECTIVE: To compare new registrations of recurrences of leprosy cases in primary healthcare units (PHUs) and in specialized units in the State of Mato Grosso. METHODS: This was a cross-sectional study based on all new registrations (N = 323) of recurrences of leprosy cases within the Notifiable Disease Information System (SINAN) between 2004 and 2006 that were made in the State of Mato Grosso, Central-West Brazil. The cases diagnosed were compared regarding sex, age, clinical-laboratory characteristics and geographical distribution among the municipalities. To compare and calculate the proportions of the variables, the chi-square test at the significance level of 5 percent was used. RESULTS: Among the new registrations of recurrences, 20 percent were confirmed at specialized units and 80 percent at PHUs. However, most of the diagnoses at PHUs presented negative bacilloscopy findings (c2 = 12.34; p = 0.002)...

OBJETIVO: Comparar las nuevas entradas por recurrencia de hanseníasis en unidades básicas de salud (UBS) y en unidades especializadas (UE) en el estado de Mato Grosso, en Centro-Oeste de Brasil. MÉTODOS: Estudio transversal con base en todos los registros (N=323) de recurrencias de hanseníasis del Sistema de Información de Agravios de Notificación (SINAN) de 2004 a 2006, notificados en el estado de Mato Grosso. Los casos diagnosticados fueron comparados con relación a sexo, edad, aspectos clínicos-laboratoriales y distribución geográfica en los municipios. Para la comparación y cálculo de las proporciones de las variables se utilizó la prueba de Chi-cuadrado con nivel de significancia de 5 por ciento. RESULTADOS: De las nuevas entradas de recurrencia, 20 por ciento fueron confirmadas en las UE y 80 por ciento en UBS; mientras que la mayoría de los diagnósticos en UBS tenían baciloscopia negativa (c2 =12,34; p = 0,002)...

Health care utilisation in Indian leprosy patients in the era of elimination.

OBJECTIVE: The health care utilisation pattern among Indian leprosy patients accessing a tertiary care centre over an 18 month period was studied. DESIGN: A study was conducted at the Dermatology Outpatient Clinic at the Christian Medical College, Vellore, from January 2005 to June 2006. The profile of patients was assessed and a subgroup was interviewed on their healthcare use, including any delays and costs incurred. RESULTS: 198 patients presented of which 115 patients (58.1%) were on treatment for leprosy or a leprosy reaction (active) including 35 new patients (17.7%), and 83 (41.9%) patients were not on active treatment (inactive). 81 patients were interviewed in depth, 14 (17.3%) were new patients included among 54 (66.7%) patients with active disease, and 27 (33.3%) with inactive disease. The average delay from the onset of symptoms to starting treatment in those interviewed was 13.4 months, 7.9 months of which was a patient-related delay and 5.4 months of which was the health care system-related delay. In patients who had been released from treatment, 78.6% (22/28) required care after cure. CONCLUSIONS: Improved awareness is required to reduce patient-related delays and systems for sustained training need to be in place to tackle the problem of health care system-related delays. Care after cure is a felt need for many patients released from treatment.

The influence of increased access to basic healthcare on the trends in Hansen's disease detection rate in Brazil from 1980 to 2006.

Brazilian Hansen's disease detection rate rose during the 80s and 90s of the 20th century. The Brazilian health system reform happened during the same period. Detection rate is a function of the real incidence of cases and the diagnostic agility of the health system. Coverage of BCG immunization in infants was used as a proxy variable for primary healthcare coverage. A log-normal regression model of detection rate as a function of BCG coverage, time and time square was adjusted to data. The detection rate presents an upward trend throughout the period and with a downturn beginning in 2003. The model showed a statistically significant positive regression coefficient for BCG coverage, suggesting that detection rate behavior reflects the improvement of access to health care. The detection rate began a trend towards decline in 2003, indicating a new phase of Hansen's disease control.

Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Machakos District, Kenya.

SETTING: Machakos District, Kenya, a rural area 50 km east of Nairobi. OBJECTIVE: To assess the cost and cost-effectiveness of new treatment strategies for tuberculosis patients, involving decentralisation of care from hospitals to peripheral health units and the community, compared to the conventional approaches to care used until October 1997. METHODS: Costs were analysed in 1998 US dollars from the perspective of health services, patients, family members and the community, using standard methods. Separate analyses were undertaken for 1) new smear-positive pulmonary patients and 2) new smear-negative and extrapulmonary patients. Cost-effectiveness was calculated as the cost per patient successfully completing treatment (smear-positive cases) and as the cost per patient completing treatment (new smear-negative and extra-pulmonary cases). FINDINGS: The cost per patient treated for new smear-positive patients was dollars 591 with the conventional hospital-based approach to care, and dollars 209 with decentralised care. Costs fell from all perspectives, and by 65% overall. Cost-effectiveness improved by 66%. The cost per patient treated for new smear-negative/extra-pulmonary patients was dollars 311 with the conventional approach to care, and dollars 197 with decentralised care. Costs fell from all perspectives, and cost-effectiveness improved by 61%. CONCLUSION: There is a strong economic case for expansion of decentralisation and strengthened community-based care in Kenya. The National Tuberculosis and Leprosy Control Programme will require new funds for start-up training and community mobilisation costs in order to do this.