Spatial analysis of epidemiological and quality indicators of health services for leprosy in hyperendemic areas in Northeastern Brazil.

Leprosy is a public health problem due to the physical disabilities and deformities it causes. This study aimed to describe new leprosy cases using an operational classification and analyzing spatial patterns by means of epidemiological and quality indicators of health services in Pernambuco State, Brazil, between 2005 and 2014. This was an ecological study performed in 184 municipalities grouped into 12 health regions units for analysis. To analyze spatial patterns, the Bayesian local empirical method and Moran's spatial autocorrelation indicator were applied and box and Moran maps were used. Individuals aged ≥15 years old, grade zero physical disability and complete remission as the treatment outcome were predominant in both paucibacillary and multibacillary cases, the only difference was the predominance of females (n=9,286; 63.00%) and males (n=8,564; 60.70%), respectively. These variables were correlated (p<0.05) with the operational classification. The overall detection rate showed three high-priority areas; the indicator rate of grade 2 physical disability revealed clusters in regions IV, V, and VI; and the indicator rate of cases with some degree of disability showed precarious municipalities in seven health regions. Pernambuco maintains an active chain of transmission and ongoing endemicity of leprosy. Therefore, spatial analysis methods allow the identification of priority areas for intervention, thereby supporting the disease elimination strategy.

One year follow up of a cohort of suspected leprosy cases: findings from a leprosy 'Selective Special Drive' in Gadchiroli district, Maharashtra, India.

OBJECTIVES: The study involves a follow-up visit in 2010, to hyper-endemic Gadchiroli district of Maharashtra, India, to evaluate the current status of those suspected in 2009 of having skin/nerve lesions suggestive of leprosy, and to study the interactions between such people and the State leprosy programme. DESIGN: The study cohort comprised of those confirmed with leprosy (n = 151 and 157/233 absentee 'suspects' who were not examined by the study team in 2009 in 14 of 45 Primary Health Centres (PHCs). At follow-up, the treatment status of the confirmed cases was checked from PHC registers and cross-checked by direct questioning of patients and their views were sought on PHC leprosy services. The 157 absentee 'suspects' were queried about the reasons for their absence. RESULTS: Thirty nine 'absentee suspects' were found to have leprosy. A notable feature of the follow-up visit was that 114 people in the communities, other than those listed as 'suspects' by Community Health Workers (CHWs), voluntarily sought out the team for their opinion on hypopigmented/anaesthetic lesions, which resulted in a further 39 new cases being brought to light. (Total new cases = 78). The follow-up revealed discrepancies (100% vs. 75%) between PHC records and testimonies of the registered patients about regularity of treatment; irregularity of MDT supply was cited by some for dropping out of treatment. Other reasons proffered for irregularity were lepra reaction, fear of stigma, ignorance about leprosy and preference for faith healers. Medical Officers of PHCs were not trained in the management of lepra reactions; that task, along with disability care being entrusted to a paramedical worker of an NGO during periodic visits. CONCLUSIONS: There are remediable lacunae in the recording and dispensing of MDT by the State apparatus, as well as a need for refresher training in leprosy diagnosis for PHC staff, and in lepra reaction management for medical officers. The large number (78) of new cases detected in the follow-up, in part of Gadchiroli district strongly suggests more to-be-discovered cases in the communities.

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.

Healthcare seeking behaviour and delay in diagnosis of leprosy in a low endemic area of China.

Delay in diagnosis of leprosy can increase the risk of nerve function impairments and promote the transmission of the infection in a community. In order to understand the factors associated with the delays in diagnosis of leprosy, a questionnaire-based interview was conducted to collect information on the delays among 88 newly diagnosed leprosy patients. The results showed that delay was common and associated with the high rate of disability in the study population. The total mean delay was 50.18 months (median 36 months). The mean patient delay was 24-4 months (median 9.5 months) and the mean health service delay was 257 months (median 12 months). Patients with leprosy reported a variety of symptoms/signs at an early stage of the disease, particularly numbness and tingling. Ignorance of the illness was reported to be the main reason for the patient's delay. Health seeking actions ranged from 1 to 50 with a mean of 7.2 after becoming aware of the first symptom/sign. The effectiveness of early diagnosis of leprosy through health promotion in the population needs to be validated and continuous training on leprosy among healthcare providers is needed.

A demenda de um Centro de Referência Nacional para Hanseníase no Nordeste Brasileiro: por que o excesso de pacientes? / The need for a national reference center in Brazil's northeastern region: why the excess of patients?

Até 2000, o controle de hanseníase no Brasil foi verticalizado. Depois desta data, o processo de descentralização desta doença deu ínicio a ações que priorizaram o nível primário de atenção à saúde. Entretanto, a assistência ainda permanece centralizada em algumas unidades, como o Centro Nacional de Referência em Dermatologia Sanitária D. Libânia (CDERM), em Fortaleza, Ceará. Este centro responde por 84% da detecção do município. O objetivo deste estudo foi investigar os fatores associados à demanda excessiva de casos em nível secundário de atenção representado por este centro de referência. Um estudo transversal foi realizado com 600 usuários selecionados aleatoriamente nos ambulatórios do CDERM. Foram coletados dados: sócio-econômico e demográficos, sobre conhecimento da doença e percepção dos serviços. Oitenta e dois por cento dos participantes tinham baixa situação socio-econômica, 90% vieram encaminhados por outras unidades de saúde e 87% tinham a forma multibacilar. Sessenta e nove por cento receberam atendimento prévio em outras Unidades de Saúde, 49% jamais ouviram falar de hanseníase, 24% referiram sentir medo da doença ou terem sofrido discriminação, 39% dos usuários referiram que o atendimento ininterrupto no horário do almoço favorece a permanência no CDERM, 57% e 27%, respectivamente, referiram que a medicação complementar nunca faltou no CDERM e nas Unidades Básicas de Saúde (UBS). Sessenta e um por cento considerou que o compromisso dos profissionais no CDERM foi ótimo contra 14% nas UBS. Os fatores relatados pelos usuários, especialmente logísticos e de qualidade de atendimento e dos profissionais, poderiam explicar a concentração de usuários neste centro de referência.

[Medicine and health in the Democratic Republic of Congo: from Independence to the Third Republic]. / Médecine et santé en République Démocratique du Congo: de l'Indépendance à la 3e République.

The birth and mortality rates in the Democratic Republic of Congo (DRC), a former Belgian colony, are high, i.e., 48.9/1000 and 17/1000 respectively. The DRC also has one of the highest maternal death rates in the world, i.e., 1289/100,000 live births. Health conditions have not improved since independence. Access to drinking water is limited, living conditions are poor, and food availability in households is low. The mean health services utilization rate in the DRC is estimated to be 0.15 visits/inhabitant/year. The incidence of transmissible diseases is rising. This increase is observed even for illnesses that were under control before independence such as sleeping sickness, onchocerciasis, leprosy, and tuberculosis. One the main causes of mortality and morbidity in the population is malaria that is responsible for the deaths of 150,000 to 250,000 children under the age of 5 every year. The HIV prevalence rate is 4.5% with 1.19 million persons with AIDS and 930,000 orphans whose parents died of AIDS. Other potentially epidemic diseases including bubonic plaque and Ebola hemorrhagic fever are serious threats. Non-transmissible diseases are also on the rise including diabetes, systemic arterial hypertension, cancer and neglected diseases such as sickle cell anemia. To meet these challenges, the country's health authorities have established a program called the Strategy for Reinforcement of the Health System (SRHS). One goal of the SRHS is to develop health zones in order to improve access to quality health care for the whole population.

Underutilization of the available services by the needy disabled leprosy patients in Government Leprosy Control Unit Puttoor, Chittoor district, Andhra Pradesh, South India.

This study was undertaken to find out the deformity profile, utilization of disability care services, factors associated with underutilization and the impact of educating leprosy patients with visible disabilities in self-care practices in the area covered by the LCU Chittoor. The disability prevalence rate in the area was 15 per 10,000 population. Training of the staff and teaching leprosy patients in self-care practices has shown a remarkable improvement in skin texture and ulcer situation of disabled leprosy patients.

[The access, utilization and acceptance of dermatology services at a teaching health center from the viewpoint of Hansen's disease patients]. / Acesso, utilização e aceitação dos serviços de dermatologia de um centro de saúde escola sob o modo de ver dos hansenianos.

The present Case Study intends to analyse the access, utilization and acceptance of the Dermatology services of a SHC based mainly in the orally reported histories of 27 patients affected by Hansen's disease. The access to SHC--concerning its organization--took place without difficulty, except for the attendance services. However, the utilization level of the services was found to be higher than the established pattern of the care provided whether in actual episodes of the disease or not. The acceptance of the services rendered was consensual and both the technical quality and interpersonal relationship were emphasized.

Illness and service utilization behaviours of leprosy patients.

225 adult leprosy patients attending the CLTRI, were interviewed to study their illness and medical agency utilization behaviours. Almost all patients perceived their disease as leprosy but 71.50% did not know how they got it. 10-11% did not reveal the disease to their family for fear of rejection. The time-lag between first suspicion and medical consultation was 1 year or more in 48% of cases. For treatment of leprosy, 36-38% of patients consulted Private Practitioners and General Hospitals, at one or the other time. 42.6% of patients changed 3 or more medical agencies for treatment. On an average patient had taken 62.39% of expected treatment. 41% of patients were not aware of the name of drug (DDS) they were taking. 44% of patients had tried home remedies. Most of the patients preferred to take treatment at leprosy referral hospitals.