Performance of the Health System Network in Formosa, Argentina, in the Diagnosis of Leprosy.

Leprosy is a chronic, neglected tropical infectious disease, currently endemic in Formosa, a province in northwestern Argentina. To analyze the performance, distribution, and effectiveness of the health system in leprosy diagnosis in Formosa, we estimated the trend of the number of new cases of leprosy diagnosed between 2002 and 2019 and estimated a forecast for 2022 at the primary health care centers (PHCCs) of at the first level of care (1stLC), at district hospitals (DHs) of the second level of care (2ndLC), high-complexity hospitals at the third level of care (3rdLC), and in rural and urban areas. The general trend was calculated based on the new cases detection rate (NCDR) using the autoregressive-moving average model (ARMA). The 1stLC, 2ndLC, and 3rdLC and the rural/urban variables were assessed using a proportional Bayesian trend ARMA (TrARMA) model. A predictive model was used for estimated forecasts. Markov-Monte Carlo chains were applied with A Metropolis-Hastings's algorithm. The highest median proportion (Mp) of new cases of leprosy was diagnosed at the 2ndLC (Mp, 0.67; 97.5% credibility interval [CI] [0.56-0.77]), at the 3rdLC (Mp, 0.11; 97.5% CI [0.08-0.15]), and in urban areas (urban median proportion (uMp), 0.86; 97.5% CI [0.83- 0.88]), whereas the lowest proportion of new cases was diagnosed at the 1stLC (Mp, 0.082; 97.5% CI [0.061-0.108]) and in rural areas (rural median proportion (rMp), 0.13; 97.5% CI [0.11-0.16]). Our model predicts for 2022 that a median number of new cases of leprosy of 19.70 will be diagnosed in urban areas (97.5% CI [15.94-23.80]), and will continue to be diagnosed at the 2ndLC (median number of cases, 15.33; 97.5% CI [12.40-10.52]) and 3rdLC (median number of cases, 2.43; 97.5% CI [1.97-2.94]).

Utilization of government healthcare services by adult leprosy patients in the Western Province, Sri Lanka.

BACKGROUND: The leprosy services utilization by the patients at the clinic and field level should be high to achieve the target of eliminating leprosy as a public health problem in Sri Lanka. Furthermore, assessing patient and health system delay of a diagnosis and patient knowledge on disease are of equal importance to reveal the accurate picture. METHODS AND FINDINGS: A descriptive cross-sectional study was conducted to assess the utilization of government healthcare services by 672 adult leprosy patients in Western Province (WP). Paucibacillary patients diagnosed at least six months and above, and Multibacillary patients diagnosed at least 12 months and above were selected by consecutive sampling method. An interviewer-administered questionnaire (IAQ) was used for data collection. Clinic utilization by leprosy patients was 87.8%. The mean patient-related delay (time taken from the onset of symptoms to the encounter of a doctor/health facility for the first time) was 16.8 months and health care system delay (time taken from the date of clinic registration to start of treatment) was 21.2 days. The overall delay was 17.5 months. Services provided by the Medical Officer of Health (MOH) office for families affected with leprosy was known by 53.8% (n = 298) of patients. Majority of family contacts were examined at the hospitals (n = 299, 44%), 30.8% (n = 207) by the Public Health Inspectors (PHI) and 7% (n = 46) at the MOH offices. PHIs had visited 56.7% (n = 401) of the patient's houses and 54% (n = 363) had received health education by PHI. Mean knowledge score was 50.7 (SD = 17.9). More than half (57.9%, n = 389) of the study sample had a good or very good knowledge level. CONCLUSIONS: Utilization of clinic services was satisfactory. However, a considerable patient-related delay was found. Half of the patients were aware of available field services and a majority of contact screening was conducted at hospitals. Patient knowledge on leprosy was satisfactory.

Leprosy post-exposure prophylaxis in the Indian health system: A cost-effectiveness analysis.

India has the highest burden of leprosy in the world. Following a recent WHO guideline, the Indian National Leprosy Programme is introducing post-exposure prophylaxis with single-dose rifampicin (SDR-PEP) in all high-endemic districts of the country. The aim of this study is to estimate the long-term cost-effectiveness of SDR-PEP in different leprosy disability burden situations. We used a stochastic individual-based model (SIMCOLEP) to simulate the leprosy new case detection rate trend and the impact of implementing contact screening and SDR-PEP from 2016 to 2040 (25 years) in the Union Territory of Dadra Nagar Haveli (DNH) in India. Effects of the intervention were expressed as disability adjusted life years (DALY) averted under three assumption of disability prevention: 1) all grade 1 disability (G1D) cases prevented; 2) G1D cases prevented in PB cases only; 3) no disability prevented. Costs were US$ 2.9 per contact. Costs and effects were discounted at 3%. The incremental cost per DALY averted by SDR-PEP was US$ 210, US$ 447, and US$ 5,673 in the 25th year under assumption 1, 2, and 3, respectively. If prevention of G1D was assumed, the probability of cost-effectiveness was 1.0 at the threshold of US$ 2,000, which is equivalent to the GDP per capita of India. The probability of cost-effectiveness was 0.6, if no disability prevention was assumed. The cost per new leprosy case averted was US$ 2,873. Contact listing, screening and the provision of SDR-PEP is a cost-effective strategy in leprosy control in both the short (5 years) and long term (25 years). The cost-effectiveness depends on the extent to which disability can be prevented. As the intervention becomes increasingly cost-effective in the long term, we recommend a long-term commitment for its implementation.

Introducing leprosy post-exposure prophylaxis into the health systems of India, Nepal and Indonesia: a case study.

BACKGROUND: Leprosy has a wide range of clinical and socio-economic consequences. India, Indonesia and Nepal contribute significantly to the global leprosy burden. After integration, the health systems are pivotal in leprosy service delivery. The Leprosy Post Exposure Prophylaxis (LPEP) program is ongoing to investigate the feasibility of providing single dose rifampicin (SDR) as post-exposure prophylaxis (PEP) to the contacts of leprosy cases in various health systems. We aim to compare national leprosy control programs, and adapted LPEP strategies in India, Nepal and Indonesia. The purpose is to establish a baseline of the health system's situation and document the subsequent adjustment of LPEP, which will provide the context for interpreting the LPEP results in future. METHODS: The study followed the multiple-case study design with single units of analysis. The data collection methods were direct observation, in-depth interviews and desk review. The study was divided into two phases, i.e. review of national leprosy programs and description of the LPEP program. The comparative analysis was performed using the WHO health system frameworks (2007). RESULTS: In all countries leprosy services including contact tracing is integrated into the health systems. The LPEP program is fully integrated into the established national leprosy programs, with SDR and increased documentation, which need major additions to standard procedures. PEP administration was widely perceived as well manageable, but the additional LPEP data collection was reported to increase workload in the first year. CONCLUSIONS: The findings of our study led to the recommendation that field-based leprosy research programs should keep health systems in focus. The national leprosy programs are diverse in terms of organizational hierarchy, human resource quantity and capacity. We conclude that PEP can be integrated into different health systems without major structural and personal changes, but provisions are necessary for the additional monitoring requirements.

Country profile: leprosy in Brazil.

Brazil has high rates of leprosy case detection, especially in the northern and west-central areas of the country. Effective decentralisation of routine treatment for leprosy has gathered pace since the year 2000 and this has improved access for patients, leading to a peak in new case detection in 2003 and a gradual decline thereafter. This is in parallel with specific government programmes aimed at poverty reduction. Disability prevention and surveillance for drug resistance remain important tasks within the leprosy control programme, in which six key referral centres lead the way.

The prevention of leprosy related disability as an integral component of the government health delivery programme in Myanmar.

This paper presents a record of a focus group discussion that took place in Nyapyitaw, Myanmar in December 2010. Those contributing to the focus group discussion were senior post holders in the National Leprosy Control Programme (NLCP), Myanmar. The Myanmar programme had been targeted for further enquiry after it became apparent, through an earlier survey of national programme managers and consultants, that the programme had been relatively successful in the measures taken to facilitate the integration of POD into the government health delivery programme. The experience gained by the NLCP, Myanmar was recorded and is offered here as an example of how POD can be successfully developed by a government leprosy control programme to become integral to general health delivery.

Government health workers as implementers of prevention of disability measures: an assessment of a prevention of disability project in selected counties of Guizhou Province, Peoples' Republic of China.

OBJECTIVE: The purpose of this study was to assess the effectiveness of government health workers as agents for the prevention of disability. DESIGN: A prevention of disability (POD) project for people affected by leprosy was conducted in nine counties of Guizhou Province, Peoples' Republic of China. The project was implemented by government health workers. In accordance with the principles and national criteria of the National Centre for Leprosy Control (NCLC) POD Pilot programme, 1215 people affected by leprosy were selected, followed up and assessed with the use of impairment summary forms through which essential indicators were routinely collected. RESULTS: Most improvements of disabilities occurred in the 1st year of the POD project. Fifty five people with neuritis were detected and treated with prednisolone out of 262 new patients; 47 of these improved; 1130 people completed a 3-year self-care programme; 88.5% of red eyes, 83.9% of hand ulcers and 62.8% of simple foot ulcer cases healed during that period. One hundred and ninety six people who presented with complicated ulcers were treated; of these 73 (37.2%) people presented with feet free of ulcers at the end of the project period. CONCLUSION: The POD project was a cost-effective method of preventing further disability occurrence among people affected by leprosy. Government health workers were generally able to implement and monitor the project effectively. Most of people affected by leprosy were satisfied that the improvements in their disabilities had been due to self-care. The programme had helped them to increase their confidence to implement self-care activities.

Capacitação técnica vs. comprometimento profissional: o real impacto no controle da hanseníase / Technical capacitation versus professional compromising: the true impact on Hansen's disease control

O objetivo deste artigo é discutir a importância que vem sendo dada às capacitações no âmbito do programa de controle da hanseníase no estado de Alagoas. Trata se de uma pesquisa de abordagem qualitativa realizada com gestores, portadores e ex portadores de hanseníase e todas as categorias profissionais das equipes de saúde da família de seis municípios selecionados a partir de indicadores operacionais padronizados pelo Ministério da Saúde do Brasil. O aspecto mais evidente que garantiu o melhor desempenho dos municípios relaciona-se ao comprometimento dos profissionais envolvidos, mais do que a sua participação em capacitações, incluindo-se, aí, o empenho, ou seja, a vontade política.

An analysis of the pattern of detection of leprosy patients by institutions in the general health services in Sri Lanka after the integration of leprosy services into general health services.

Integration of leprosy services into the General Health Services was initiated in 2001 in Sri Lanka, and by the end of 2003 all services related to leprosy care were fully integrated. Against this background, routinely collected data available at the Anti-Leprosy Campaign for a 3-year period from 2000-2003 were analyzed to identify the pattern of the detection of cases by hierarchical institutions in the General Health Services. The analysis showed that more than 75% of leprosy patients had been detected at base, general and teaching hospitals and this trend was increasing proportionally during the period of concern (P < 0.001). Teaching hospitals had detected more than 50% of patients and this trend was also proportionally increasing. Nearly one-third of patients detected at teaching hospitals had been detected at the Central Leprosy Clinic (CLC) at the National Hospital. The trend for case detection at the CLC was decreasing proportionally and in absolute terms during the 3-year period after integration. More than 60% of leprosy patients had been detected at institutions where consultant dermatologists were available. The analysis concluded that centralized leprosy diagnostic and treatment services have been taken over by the institutions in the General Health Services but within districts these activities are predominantly concentrated on higher level institutions with consultant dermatological services. This suggests that similar to the existing general trend of by passing of lower level institutions by patients to seek treatment at higher-level institutions, which are perceived to provide a service of better quality, leprosy patients too prefer to seek treatment at these institutions.

Qualitative assessment of social, economic and medical needs for ex-leprosy patients living in leprosy villages in Shandong Province, The People's Republic of China.

After successful control of the endemic of leprosy in Shandong Province, China, how to deal with ex-leprosy patients living in the leprosy villages/leprosaria has become a hot topic among programme managers, medical staff and governmental officials at different levels. One of the possible solutions in dealing with the problem was proposed to combine small leprosy villages into a few larger, already existing, leprosaria/leprosy villages with better facilities, in order to provide better care for ex-leprosy patients and make better use of existing resources. With this assumption, social, economic and medical needs felt by ex-leprosy patients in three leprosy villages of Shandong province were assessed qualitatively, and the possibilities and obstacles regarding combination were explored. The results showed that the basic needs for living, such as food and clothes, were provided by state governments, although living standards remained at a low level. Medical care was not satisfactory, as many health problems related and unrelated to leprosy were increasing, and self-care needed to be addressed, as the dependents grew older and the disability status became worse. Although the majority of ex-leprosy patients, medical staff and government officials interviewed agreed with the idea of the adjustment of leprosy villages/leprosaria, some obstacles, including stigma, existed. Government commitment, ideally at top level, was needed in order to facilitate the process of combination.

Leprosy control in the Republic of Yemen: co-operation between government and non-government organizations, 1989-2003.

Although the prevalence rate of leprosy in the Republic of Yemen has dropped below the WHO elimination level of less than one case per 10,000 of the population, it is still regarded as a serious public health problem calling for continued vigilance, notably in the detection and treatment of hidden and undiagnosed cases. In the past, religious misinterpretation has generated adverse behaviour patterns towards people affected by leprosy, characterized by aggression, negligence and isolation. Until about 1982, following a visit of a leprologist (Dr S. K. Noordeen) from the World Health Organization, there was no leprosy control programme and attempts to establish one remained ineffective until in 1989, when an agreement was signed between the Ministry of Public Health and Population and the German Leprosy Relief Association. This led to the development of a leprosy control programme in four governorates, later extended to the rest of the country. This paper describes the progress made in the control of leprosy in the Yemen, 1989-2003, by the Ministry of Health and Population and the GLRA, in association with two local societies.

Current epidemiology of leprosy.

Every year around 4,00,000 new cases of leprosy occur in India and India contributes about 80% of the global leprosy case load. The prevalence of leprosy (case load per 1,00,000 population) has come down from 52 per 10,000 in 1981 to 2.4 per 10,000 in July 2004. There is no primary prevention for leprosy. Multidrug therapy is the only intervention available against the disease. As of July 2004 there were about 2,40,000 leprosy cases on record in India. There are thirteen states and union territories in India which have already eliminated leprosy. About 70% of the cases detected in India are paucibacillary which are less or non-infectious. Ever since the start of National Leprosy Eradication Programme in 1983, the number of new cases detected every year has not shown significant change. Leprosy cases are treated for 6 months or 12 months depending on whether they are PB or MB. The treatment completion rates are now found to be 85% for MB and 90% for PB. Phased introduction of MDT services has contributed to a large extent the static level of new case detection. Without complete coverage of MDT, it is difficult to achieve stable level of new case detection. Diagnostic efficiency of the staff is very important external factor influencing case detection rate. The most important factor that could have significant impact or prevalence is the coverage of the entire population with adequate MDT service.

National Leprosy Eradication Programme and progress towards elimination of leprosy in India.

The World Health Assembly in May 1991 made the declaration to eliminate leprosy at global level by the year 2000. Complete coverage of all the districts with MDT was possible in the year 1996. Very good results were obtained and the case lead came down to 0.51 million by December 2000. A new goal has been set to reach leprosy elimination at national level in India by December 2005. The challenges to eliminate leprosy and to bring prevalence rate 0.9/10,000 by December 2005 are to be taken at epidemiological, operational and at administrative levels.

Counselling of leprosy affected persons and the community.

"Counselling is a helping process where one person explicitly and purposefully gives his/her time, attention and skills to assist a client to explore their situation, identity and act upon solutions within the limitations of their given environment". The GATHER (greet, ask, tell, help, explain, return visit) technique can be useful in successful counselling. Counselling services have been proven successful in reducing stigma. While the scope for counselling is quite enormous, it will vary according to the specific need. The few common points which have been detailed in the text must be followed by all while providing counselling in different situations. The points as specified are: (1) Counselling of new patients. (2) Counselling of patients under treatment for few months. (3) Counselling of patients on completion of treatment. (4) Counselling of family members. (5) Counselling of community members. The points mentioned are about issues on which counselling should be centred.