Estrategias para o exame de contatos de hanseniase: avaliacao de desempenho em area urbana endemica do Rio Janeiro / Strategies for the leprosy contact exam: performance evaluation on the Rio de Janeiro´s urban endemic area

Fundamentacao teorica: Tendo em vista a meta de eliminacao da hanseniase de atingir uma prevalencia de menos de 1 doente em 10 mil habitantes, a vigilancia de contatos, por ser o grupo de maior risco, e o diagnostico precoce, tem sido prioritarios nos programas de controle da doenca. Apesar da recomendacao atual de examinar todos os contatos intradomiciliares dos casos novos de todas as formas clinicas de hanseniase, o cumprimento desta norma vem sendo negligenciado no pais. O municipio de Duque de Caxias apresenta prevalencia e incidencia de hanseniase de 6,17 e 4,09 por 10 mil habitantes, indicadores considerados alto e hiperendemico. A ausencia de dados oficiais sobre o exame de contatos nesta regiao sugere a baixa efetividade desta medida, estimulando o estudo em questao. Objetivos: Avaliar o desempenho da vigilancia de contatos na rotina, em campanhas e em visitas domiciliares, realizadas no segundo distrito de Duque de Caxias, quanto a deteccao de casos novos e o diagnostico precoce, utilizando as variaveis: numero de casos novos em contatos, número de lesoes cutaneas, forma clinica e grau de incapacidade fisica. Avaliar as taxas de deteccao de casos novos e as proporcoes de formas clinicas precoces encontrados antes e apos as intervencoes, no segundo distrito e no municipio. Delineamento do estudo: Estudo de intervencao comunitario, controlado, no segundo distrito de Duque de Caxias em comparacao com os demais distritos. Foram 2 intervencoes: campanhas de sintomaticos dermatologicos focalizadas, em 2002 e 2003. A coleta de dados foi feita a partir do banco SINAN e questionarios do projeto. Resultados: As campanhas foram 5 e 10 vezes mais eficientes na deteccao de casos em contatos, em relacao a rotina em 2002 e as visitas domiciliares em 2003, tendo apresentado percentual de deteccao de 13,9 contra 2,5 e 1,3, respectivamente. O diagnostico precoce, isto é, o grau 0 de incapacidade fisica, foi alcancado em 100% dos contatos diagnosticados nas campanhas e em 91,7% dos contatos das visitas. Com uma cobertura de 86,6%, aas visitas possibilitaram examinar 56,8% dos contatos domiciliares nao examinados anteriormente pela rotina. As intervencoes em conjunto incrementaram em 100% e 150% a deteccao em contatos na area do estudo, tendo produzido efeito em menos escala, no municipio. O segundo distrito diagnosticou o maior numero de casos da forma indeterminada e com grau 0 de incapacidades comparado com os demais distritos, nos anos das intervencoes...

The anti-leprosy compaign in Colômbia: the rhetoric of higiene and science, 1920-1940

Desde a década de 1920, a comunidade médica percebeu que o controle da hanseníase baseada na segregação dos pacientes erea ineficaz e dispendiosa. Na década de 1930, o novo governo, mais liberal, incorporou a hanseníase às instituições sanitárias gerais, ao fundir o Serviço de Leprosários ao Departamento Nacional de Higiene. O isolamento começou a ser substituído por uma estratégia geral de saúde pública, que envolvia outras doenças. Prevenção e pesquisa foram valorizados, e as autoridades passaram a ver a hanseníase à luz da racionalidade econômica, enfatizando as terapias e tornando-as obrigatórias. Os avanços no tratamento tornaram-se largamente disponíveis. Entretanto, a imagem da hanseníase como doença especial e a segregação de seus doentes estavam profundamente arraigados na cultura e nas instituições colombianas. A retórica mudou, mas acabar com várias décadas de perseguição não foi tarefa fácil

Progress towards elimination of leprosy as a public health problem in India and role of modified leprosy elimination campaign.

India (population 943 million) has seen a highly significant decrease in the prevalence of leprosy since the introduction of multi-drug therapy (MDT) in 1981. From a prevalence rate of 57/10,000 of the population in March 1981, the figure has declined to 5.2/10,000 in March 1999. This was possible due to the creation of a completely vertical (specialized) infrastructure for leprosy control in the 218 endemic districts of the country and skeleton vertical staff in the remaining districts, coupled with the recruitment of additional staff on contract basis to provide MDT through vertical staff in endemic districts and mobile treatment units in the moderate and low endemic districts. Despite all efforts, however, new case detection has not shown a decline over the last 14 years due to the presence of hidden (and undiagnosed) cases. Therefore, in order to intensify and hasten progress towards elimination (less than 1 case per 10,000 of the population) in the whole country, it was decided to implement a massive leprosy elimination campaign (LEC) in all the States/Union Territories (UTs). The reports of 22 States/UTs indicate that 415 out of the total of 490 districts in the country were covered by modified LEC (MLEC), with 85% coverage of the population. The campaign used in India was modified from the pattern previously described by the World Health Organization. The detection of hidden or suspected cases took place within a short, intensive period of 6-7 days and relied heavily on house-to-house searches by General Health Care staff trained in leprosy detection and confirmation was made by appropriately trained staff. This MLEC received widespread Government and public support, resulting in the detection of 454,290 hidden cases of leprosy, whilst providing training to a large number of General Health Care staff and volunteers and creating widespread awareness about leprosy and the availability of treatment free of charge for all cases. This programme proved to be one of the most successful health care interventions undertaken in India in recent years, particularly in the states of Bihar and Orissa. Although a few states in India are unlikely to reach the current WHO goal of elimination before end of the year 2000, the results of the MLEC strongly support the possibility that elimination levels will be achieved in the majority of states by the end of the year 2000 and at national level by the end of the year 2002.

Future scope and expectations: why, when, and how LECs should continue.

There is a strong case to continue to use LEC approaches, as they are a comprehensive and cost effective means of delivering the key elements of leprosy control. LECs should be conducted when there is evidence of large numbers of hidden cases. Probably a minimum of two LECs is required but where large number of new cases continue to be detected they could be run on an annual basis. The methodology of LECs needs to be improved through experience, evaluation and from LECs conducted elsewhere; feedback from the community is also important. There is room to improve all aspects of LECs: planning, training, education, diagnosis and treatment completion.

Health information systems for leprosy control programmes: a case for quality assessment.

A qualitative study was carried out aimed at checking the level of understanding and the actual use of the indicators recommended in leprosy control programmes by either the World Health Organization or the International Federation of Anti-Leprosy Associations. Two successive questionnaires were sent to 268 leprosy control programme managers. The first one concerned information about the main characteristics of the programme, the information system in operation, and the data regarded as indispensable or useful for programme monitoring. The respondents to the first questionnaire (n = 64) proposed an extraordinarily wide range of indicators, mainly ill-defined. The respondents to the second questionnaire (n = 37) to whom a limited list of precisely defined indicators was submitted did not succeed in reaching a complete agreement on any of these indicators. Although the question of programme monitoring has been dealt with at an international level for years, there is an urgent need for a real agreement of international agencies and managers of leprosy control programmes on the indicators to be used. Programme managers in the field are obviously open to the idea of greater intervention by international organizations to improve data collection and to encourage standardization of computerized information systems.