ABSTRACT

Objective:

To analyze the temporal trend of healthcare services quality indicators to reduce leprosy in Brazil, over a 20-year period.

Methods:

This is an epidemiological study with a temporal trend, whose data were extracted from the Notifiable Diseases Information System. Indicators were constructed from the Ministry of Health Technical-Operational Manual that presents the Guidelines for Surveillance, Care and Elimination of Leprosy as a Public Health Problem. For trend analysis of the selected indicators, the Prais-Winsten model was used and the Average Annual Growth Rate (AAGR) was also calculated.

Results:

In the 20-year time series investigated here, 732,959 cases of leprosy were reported in Brazil. The trend was stationary for: new leprosy cases cure rate (β=-0.000; p=0.196; AAGR=-0.2), new leprosy cases drop out rate (β=-0.001; p=0.147; AAGR=-0.4), new leprosy cases contact tracing rate (β=-0.001; p=0.112; AAGR=1.6), new cases of leprosy with degree physical disability assessment rate among new cases (β=-0.000; p=0.196; AAGR=-0.2) and cases cured in the year with the degree of physical disability assessed (β=0.002; p=0.265; AAGR=0.5); while the indicator of recurrence rate among cases reported in the year (β=0.019; p<0.001; AAGR=0.5) showed an increasing trend.

Conclusion:

Based on the evaluation of indicators to assess the quality of healthcare services to reduce leprosy, it was evident that Brazil has major challenges for its full implementation, with improvements being necessary in the quality of care service offered to the population.

Keywords:
Epidemiology; Temporal distribution; Leprosy; Health status indicators; Public health

INTRODUCTION

Leprosy remains a significant public health challenge due to its widespread prevalence and considerable disability impact, particularly affecting vulnerable and marginalized populations in middle and low-income countries¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Guia prático sobre a hanseníase [Internet]. Brasília: Ministério da Saúde; 2017 [cited on Aug 14, 2023]. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/guia_pratico_hanseniase.pdf
https://bvsms.saude.gov.br/bvs/publicaco... . Despite the implementation of policies and programs by the Ministry of Health aimed at its eradication²2. Costa MS, Silva Júnior PCB, Moura JPG, Pantoja PVN, Silva MP. Políticas para hanseníase: a evolução da gestão em saúde. Rev Enf 2015; 1(2): 104-8. https://doi.org/10.5935/2446-5682.20150018
https://doi.org/10.5935/2446-5682.201500... , leprosy continues to exhibit a high prevalence in Brazil³3. World Health Organization. Global leprosy (Hansen disease) update, 2021: moving towards interruption of transmission [Internet]. Geneva: WHO; 2022 [cited on Aug 14, 2023]. Available at: https://www.who.int/publications/i/item/who-wer9736-429-450
https://www.who.int/publications/i/item/... — which, globally, ranks second in number of reported cases — being classified, therefore, as a neglected disease with the potential for elimination³3. World Health Organization. Global leprosy (Hansen disease) update, 2021: moving towards interruption of transmission [Internet]. Geneva: WHO; 2022 [cited on Aug 14, 2023]. Available at: https://www.who.int/publications/i/item/who-wer9736-429-450
https://www.who.int/publications/i/item/... .

In 2020, a total of 127,396 new cases of leprosy were reported worldwide. Within the American continent, 19,195 (15.1%) cases were registered; of these, 17,979 were reported in Brazil, corresponding to 93.6% of the new cases reported in the Americas⁴4. World Health Organization. Global leprosy update, 2020: impact of COVID-19 on global leprosy control. Weekly Epidemiological Record 2021; 36: 421-44..

In the 1980s, the World Health Organization (WHO) introduced polychemotherapy (poly-CT) as the treatment protocol for leprosy, a measure aimed at halting transmission and preventing deformities, which was also adopted in Brazil⁵5. Brasil. Ministério da Saúde. Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Legislação sobre o controle da hanseníase no Brasil [Internet]. Brasília: Ministério da Saúde; 2000 [cited on Nov 03, 2023] Available at: https://docs.bvsalud.org/biblioref/2022/06/1236038/ms18.pdf
https://docs.bvsalud.org/biblioref/2022/... . Subsequently, in 2002, the Ministry of Health established operational indicators to evaluate the effectiveness of interventions and services aimed at reducing and monitoring leprosy⁶6. Ministério da Saúde. Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Guia para o controle da hanseníase [Internet]. Brasília: Ministério da Saúde; 2002 [cited on Aug 14, 2023]. Available at: https://bvsms.saude.gov.br/bvs/publicacoes/guia_de_hanseniase.pdf
https://bvsms.saude.gov.br/bvs/publicaco... . In 2016, with the publication of the Guidelines for Surveillance, Care, and Elimination of Leprosy as a Public Health Problem, operational indicators were designed to assess the quality of healthcare services in reducing leprosy⁷7. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Diretrizes para vigilância, atenção e eliminação da Hanseníase como problema de saúde pública: manual técnico-operacional [Internet]. Brasília: Ministério da Saúde; 2016 [cited on Aug 14, 2023]. Available at: https://portal.saude.pe.gov.br/sites/portal.saude.pe.gov.br/files/diretrizes_para_._eliminacao_hanseniase_-_manual_-_3fev16_isbn_nucom_final_2.pdf
https://portal.saude.pe.gov.br/sites/por... .

While literature offers studies on trend analysis of leprosy indicators, they predominantly concentrate on local and/or regional contexts, lacking publications with national coverage⁸8. Souza CDF, Matos TS. Análise de tendência dos indicadores de monitoramento e avaliação da qualidade dos serviços de hanseníase em município prioritário do Nordeste brasileiro. Rev Bras Pesqui Saúde 2018; 19(4): 74-83.

9. Lima LV, Pavinati G, Silva IGP, Moura DRO, Gil NLM, Magnabosco GT. Temporal trend, distribution and spatial autocorrelation of leprosy in Brazil: ecological study, 2011 to 2021. Rev Bras Epidemiol 2022; 25: e220040. https://doi.org/10.1590/1980-549720220040
https://doi.org/10.1590/1980-54972022004... -¹⁰10. Barros ICA, Sousa CCM, Silva NRF, Mascarenhas MDM. Characterization of cases and epidemiological and operational indicators of leprosy: analysis of time series and spatial distribution, Piauí state, Brazil, 2007-2021. Epidemiol Serv Saúde 2024; 33: e2023090. https://doi.org/10.1590/S2237-96222024v33e2023090.en
https://doi.org/10.1590/S2237-96222024v3... . Furthermore, these studies often assess indicators over short time intervals⁹9. Lima LV, Pavinati G, Silva IGP, Moura DRO, Gil NLM, Magnabosco GT. Temporal trend, distribution and spatial autocorrelation of leprosy in Brazil: ecological study, 2011 to 2021. Rev Bras Epidemiol 2022; 25: e220040. https://doi.org/10.1590/1980-549720220040
https://doi.org/10.1590/1980-54972022004... ,¹¹11. Anchieta JJS, Costa LMM, Campos LC, Vieira MR, Mota OS, Morais Neto OL, et al. Trend analysis of leprosy indicators in a hyperendemic Brazilian state, 2001–2015. Rev Saúde Pública 2019; 53: 61. https://doi.org/10.11606/S1518-8787.2019053000752
https://doi.org/10.11606/S1518-8787.2019... . Another notable gap is the limited research evaluating the quality of healthcare services aimed at reducing leprosy, as the majority of studies have focused on epidemiological indicators¹¹11. Anchieta JJS, Costa LMM, Campos LC, Vieira MR, Mota OS, Morais Neto OL, et al. Trend analysis of leprosy indicators in a hyperendemic Brazilian state, 2001–2015. Rev Saúde Pública 2019; 53: 61. https://doi.org/10.11606/S1518-8787.2019053000752
https://doi.org/10.11606/S1518-8787.2019...

12. Souza CDF, Paiva JPS, Leal TC, Urashima GS. Hanseníase no Brasil no século XXI: análise dos indicadores epidemiológicos e operacionais utilizando regressão por pontos de inflexão. An Bras Dermatol 2020; 95(6): 743-7. https://doi.org/10.1016/j.abdp.2020.09.019
https://doi.org/10.1016/j.abdp.2020.09.0... -¹³13. Basso MEM, Andrade RF, Silva RLF. Trend of epidemiological indicators of leprosy in an endemic state of the Amazon region. Rev Gaucha Enferm 2021; 42: e20190520. https://doi.org/10.1590/1983-1447.2021.20190520
https://doi.org/10.1590/1983-1447.2021.2... .

Therefore, studies employing indicators to assess the quality of healthcare services aimed at reducing leprosy at a national level enable the monitoring of the impact of already implemented public policies. They also offer support to health managers in planning, decision-making, and program execution or improvements addressing the issue of leprosy in Brazil. Consequently, this study aimed to analyze the temporal trend of quality indicators of healthcare services to reduce leprosy in Brazil over a 20-year period.

METHODS

This epidemiological study examined temporal trends using indicators to assess the quality of healthcare services aimed at reducing leprosy in Brazil, encompassing a historical series from 2001 to 2020.

The data were sourced from the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação – SINAN) of the Ministry of Health, managed by the Information Technology Department of the Unified Health System (Departamento de Informática do Sistema Único de Saúde – DATASUS)¹⁴14. Brasil. Ministério da Saúde. Sistema de Informação de Agravos de Notificação. Departamento de Informática do Sistema Único de Saúde. Acompanhamento dos dados de hanseníase – Brasil [Internet]. [cited on Nov 10, 2022]. Available at: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinannet/cnv/hanswbr.def
http://tabnet.datasus.gov.br/cgi/tabcgi.... . Notifications with code A-30 were specifically chosen, falling under the “leprosy” category, recorded within the selected timeframe, and classified according to the criteria of the International Statistical Classification of Diseases and Related Health Problems (Tenth Revision), ICD-10¹⁵15. Organização Mundial da Saúde. Classificação estatística internacional de doenças e problemas relacionados à saúde – CID-10. São Paulo: Edusp; 1994..

To assess the quality of healthcare services aimed at reducing leprosy, six indicators were employed. These indicators were derived from the Technical-Operational Manual, which outlines the Guidelines for Surveillance, Care, and Elimination of Leprosy as a Public Health Problem, issued by the Ministry of Health⁷7. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Diretrizes para vigilância, atenção e eliminação da Hanseníase como problema de saúde pública: manual técnico-operacional [Internet]. Brasília: Ministério da Saúde; 2016 [cited on Aug 14, 2023]. Available at: https://portal.saude.pe.gov.br/sites/portal.saude.pe.gov.br/files/diretrizes_para_._eliminacao_hanseniase_-_manual_-_3fev16_isbn_nucom_final_2.pdf
https://portal.saude.pe.gov.br/sites/por... (Chart 1).

The database was constructed using Microsoft Excel software, facilitating the calculation of proportions. Statistical analyses to assess the temporal trend and AAGR were conducted using the Stata statistical package (version 13.0).

To analyze the trend of indicators for assessing the quality of healthcare services aimed at reducing leprosy in Brazil, the Prais-Winsten linear regression test was employed¹⁶16. Antunes JLF, Cardoso MRA. Uso da análise de séries temporais em estudos epidemiológicos. Epidemiol Serv Saúde 2015; 24(3): 565-76. https://doi.org/5123/S1679-49742015000300024
https://doi.org/5123/S1679-4974201500030... . The proportions corresponding to each evaluated indicator were considered as dependent variables, with the independent variable being the years within the historical series.

In the trend analysis, the β value of the proportions for each evaluated indicator was derived, representing the slope of the straight line. The rate of variation was utilized to classify the trend as follows: a positive rate of variation indicates an increasing time series, a negative rate of variation indicates a decreasing trend, and the trend is considered stationary when there is no significant difference between its value and zero. The level of significance was determined by comparing the p-value with the value provided by the standard normal curve, with a 95% Confidence Interval (CI). For all indicators, those with a model estimate yielding a p-value of <0.05 were deemed significant¹⁷17. Gonçalves ICM, Freitas RF, Aquino EC, Carneiro JA, Lessa AC. Mortality trend from falls in Brazilian older adults from 2000 to 2019. Rev Bras Epidemiol 2022; 25: e220031. https://doi.org/10.1590/1980-549720220031.2
https://doi.org/10.1590/1980-54972022003... .

The quantitative estimate of the trend is calculated by the following equation:

β corresponds to the angular coefficient formed in the linear regression.

To calculate the CI of the study measurements, the following formula was used:

t = value at which Student’s t distribution has 19 degrees of freedom at a two-tailed 95% CI;

SE = standard error of the estimate of β, provided by the regression analysis.

For all statistical tests performed, a significance level of 5% was adopted. Therefore, values of p≤0.05 were considered significant.

Following the criteria established by Resolution No. 466/2012¹⁸18. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Resolução no 466, de 12 de dezembro de 2012. Aprova diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos [Internet]. 2012 [cited on May 03, 2023]. Available at: https://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf
https://conselho.saude.gov.br/resolucoes... and Resolution No. 510/2016¹⁹19. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Resolução no 510, de 07 de abril de 2016 [Internet]. 2016 [cited on May 03, 2023]. Available at: https://conselho.saude.gov.br/resolucoes/2016/Reso510.pdf
https://conselho.saude.gov.br/resolucoes... of the National Health Council for research involving human subjects, studies that utilize publicly accessible information, as per the terms of Law No. 12.527²⁰20. Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei no 12.527, de 18 de novembro de 2011. Regula o acesso a informações previsto no inciso XXXIII do art. 5º, no inciso II do § 3º do art. 37 e no § 2º do art. 216 da Constituição Federal; altera a Lei no 8.112, de 11 de dezembro de 1990; revoga a Lei no 11.111, de 5 de maio de 2005, e dispositivos da Lei no 8.159, de 8 de janeiro de 1991; e dá outras providências [Internet]. 2011 [cited on May 03, 2023]. Available at: https://www.planalto.gov.br/ccivil_03/_ato2011-2014/2011/lei/l12527.htm
https://www.planalto.gov.br/ccivil_03/_a... , dated November 18, 2011, are not required to be registered or evaluated by the Research Ethics Committee (Comitês de Ética em Pesquisa – CEP)/National Commission for Ethics in Research (Comissão Nacional de Ética em Pesquisa – CONEP).

RESULTS

In the 20-year time series under investigation, a total of 732,959 cases of leprosy were reported in Brazil. Within this period, 545,610 cases of cure were documented. The overall proportion of leprosy cure among new cases diagnosed throughout the cohort years from 2001 to 2020 was 84.49%. The lowest proportion of cure was observed in 2019, while the highest was in 2007. Regarding the indicator for evaluating service quality, all years in the series — except for 2019, which was classified as precarious — were labeled as regular. This suggests that despite efforts to control and treat leprosy, effectiveness remains incomplete in Brazil (Table 1).

Regarding treatment abandonment, among new cases diagnosed in the cohort years, 34,999 cases were registered. The proportion of abandonment over the 20-year time series was 5.42%. The year with the highest number of abandonments was 2019, recording 1,971 cases, while the lowest number was in 2011 (1,425). In terms of the health care service quality parameter for the treatment abandonment indicator, all years received a good rating. During the investigated period, 2,131,711 contacts of new leprosy cases diagnosed in the cohort years were recorded, with 1,439,380 examined, representing a proportion of 67.5%. From 2001 to 2010, the quality of health service regarding the proportion of examined contacts of new leprosy cases diagnosed in the cohort years was classified as precarious. From 2011 to 2020, they were classified as regular, indicating the need to enhance health surveillance services (Table 1).

Over the span of 20 years, 30,873 cases of recurrence were recorded, constituting a proportion of 4.1 among the cases reported during this period. The highest proportion of relapse occurred in 2018, while the lowest was observed in 2001. Regarding the proportion of new leprosy cases with a degree of physical disability assessed at diagnosis, an average of 88.9% was noted from 2001 to 2020. During this period, only the years 2006, 2009, 2010, and 2011 received a good classification for this indicator. The remaining years were classified as regular (Table 2).

Regarding the proportion of cases cured in the year with the degree of physical disability assessed among new cases of leprosy in the cohort period, the average proportion observed between 2001 and 2019 was 67.8%. This result was considered precarious (Table 2).

In the temporal trend analysis of health service quality indicators to reduce leprosy in Brazil, a stationary trend was observed for the following indicators: proportion of leprosy cure among newly diagnosed cases (AAGR=-0.2; 95%CI=-0.5-0.1); proportion of leprosy cases that abandon treatment among new cases diagnosed (AAGR=-0.4; 95%CI=-1.5-0.2); proportion of examined contacts of newly diagnosed leprosy cases (AAGR=1.6; 95%CI=-0.4-3.6); proportion of new leprosy cases with degree of physical disability assessed at diagnosis (AAGR=-0.2; 95%CI=-0.5-0.1); and proportion of cured cases in the year with the degree of physical disability assessed among new leprosy cases in the cohort period (AAGR=0.5; 95%CI=-0.4-1.5). However, the indicator of proportion of recurrence cases among cases reported in the year (AAGR=0.5; 95%CI=-0.4-1.5) showed an increasing trend (Table 3).

DISCUSSION

The findings of this study highlight the precarious quality of care for individuals diagnosed with leprosy, as well as shortcomings in surveillance capabilities and the effectiveness of actions for early case detection. These findings indicate a deviation from the standards recommended by the WHO²¹21. Organização Mundial da Saúde. Rumo à zero hanseníase. Estratégia global para a hanseníase 2021-2030 [Internet]. Nova Deli: OMS, 2021 [cited on May 03, 2023]. Available at: https://www.who.int/pt/publications/i/item/9789290228509
https://www.who.int/pt/publications/i/it... .

The trend analysis of the leprosy cure proportion indicator revealed unsatisfactory outcomes for individuals affected by the disease until the completion of treatment and achieving cure. A study conducted in Maranhão between 2002 and 2015, a period similar to that of the data presented here, also found a stationary trend for this indicator, that is, no progress in the number of cured cases²²22. Anchieta JJS, Costa LMM, Campos LC, Vieira MR, Mota OS, Morais Neto OL, et al. Trend analysis of leprosy indicators in a hyperendemic Brazilian state, 2001–2015. Rev Saude Publica 2019; 53: 61. https://doi.org/10.11606/S1518-8787.2019053000752
https://doi.org/10.11606/S1518-8787.2019... . Similarly, Machado²³23. Machado RNR. Descentralização das ações de controle da hanseníase nos clusters de risco do Brasil [dissertação de mestrado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2019., in a historical series from 2003 to 2015, analyzing risk clusters for leprosy in Brazil, observed a stationary trend for the cure rate in most clusters, specifically in 14 out of the 15 analyzed. This underscores the importance of involving health professionals in the treatment adherence process and the necessity for health education programs to enhance individuals’ knowledge about leprosy. Improving the proportion of cured cases can facilitate the interruption of transmission and reduce instances of disability²³23. Machado RNR. Descentralização das ações de controle da hanseníase nos clusters de risco do Brasil [dissertação de mestrado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2019.,²⁴24. Machado LMG, Santos ES, Cavaliero A, Steinmann P, Ignotti E. Spatio-temporal analysis of leprosy risks in a municipality in the state of Mato Grosso-Brazilian Amazon: results from the leprosy post-exposure prophylaxis program in Brazil. Infect Dis Poverty 2022; 11(1): 21. https://doi.org/10.1186/s40249-022-00943-7
https://doi.org/10.1186/s40249-022-00943... .

The temporal trend of the indicator proportion of leprosy cases abandoning treatment was investigated, as it is inversely proportional to the effectiveness of the leprosy control program²⁵25. Souza EA, Boigny RN, Ferreira AF, Alencar CH, Oliveira MLW, Ramos Júnior AN. Vulnerabilidade programática no controle da hanseníase: padrões na perspectiva de gênero no Estado da Bahia, Brasil. Cad Saúde Pública 2018; 34(1): e00196216. https://doi.org/10.1590/0102-311X00196216
https://doi.org/10.1590/0102-311X0019621... , and it showed a stationary trend. A study conducted in Brazil between 2001 and 2015 reported an increase in the proportion of leprosy treatment abandonment²⁶26. Felix Junior E, Santos VC, Paixão AS, Sampaio KCP, Anjos KF. Perfil epidemiológico da hanseníase no Brasil no período de 2001 a 2015. Revista Brasileira de Saúde Funcional 2018; 6(1): 60-9. https://doi.org/10.25194/rebrasf.v6i3.1010
https://doi.org/10.25194/rebrasf.v6i3.10... . These findings highlight the low effectiveness of the strategy to reduce treatment abandonment²⁷27. Lira KB, Leite JJG, Maia DCBSC, Freitas RMF, Feijão AR. Knowledge of the patients regarding leprosy and adherence to treatment. Braz J Infect Dis 2012; 16(5): 472-5. https://doi.org/10.1016/j.bjid.2012.04.002
https://doi.org/10.1016/j.bjid.2012.04.0... , which could result in subtherapeutic dosing, leading to drug resistance and treatment failure²⁵25. Souza EA, Boigny RN, Ferreira AF, Alencar CH, Oliveira MLW, Ramos Júnior AN. Vulnerabilidade programática no controle da hanseníase: padrões na perspectiva de gênero no Estado da Bahia, Brasil. Cad Saúde Pública 2018; 34(1): e00196216. https://doi.org/10.1590/0102-311X00196216
https://doi.org/10.1590/0102-311X0019621... ,²⁸28. Moraes MO. Editorial commentary: Drug-resistance in leprosy: moving toward understanding the scope of the problem and how to tackle it. Clin Infect Dis 2016; 63(11): 1485-6. https://doi.org/10.1093/cid/ciw574
https://doi.org/10.1093/cid/ciw574... .

The indicator proportion of examined contacts of newly diagnosed leprosy cases exhibited a stationary trend, indicating that the capacity of services to conduct surveillance of new leprosy cases and promptly detect them is still considered precarious. Despite an improvement in classification during the second decade, transitioning from precarious to regular, the onset of the COVID-19 pandemic in 2020 likely caused a decline in the proportion, resulting in the indicator being classified as precarious once again. In a historical series presented by Souza et al.²⁹29. Souza EA, Ferreira AF, Pinto MSAP, Heukelbach J, Oliveira HX, Barbosa JC, et al. Desempenho da vigilância de contatos de casos de hanseníase: uma análise espaço-temporal no Estado da Bahia, Região Nordeste do Brasil. Cad Saúde Pública 2019; 35(9): e00209518. https://doi.org/10.1590/0102-311X00209518
https://doi.org/10.1590/0102-311X0020951... , with data from the state of Bahia spanning from 2003 to 2014, an increasing trend was observed; however, even with this trend, the indicator was still classified as precarious. The approach to contacts is crucial for disease control, as it can provide counseling and systematic long-term monitoring of individuals and families at risk of illness, considering the disease’s spread characteristics²⁹29. Souza EA, Ferreira AF, Pinto MSAP, Heukelbach J, Oliveira HX, Barbosa JC, et al. Desempenho da vigilância de contatos de casos de hanseníase: uma análise espaço-temporal no Estado da Bahia, Região Nordeste do Brasil. Cad Saúde Pública 2019; 35(9): e00209518. https://doi.org/10.1590/0102-311X00209518
https://doi.org/10.1590/0102-311X0020951... .

Regarding the indicator proportion of new leprosy cases with degree of physical disability assessed at diagnosis, this indicator exhibited a stationary trend, maintaining a regular pattern throughout all years of the series. In the state of Paraíba, this indicator also demonstrated a stationary trend from 2001 to 2014; however, its classification remained precarious throughout the series, not exceeding 59%³⁰30. Brito KKG, Andrade SSC, Santana EMF, Peixoto VB, Nogueira JA, Soares MJGO. Epidemiological analysis of leprosy in an endemic state of northeastern Brazil. Rev Gaúcha Enferm 2015; 36(spe): 24-30. https://doi.org/10.1590/19831447.2015.esp.55284
https://doi.org/10.1590/19831447.2015.es... . Conversely, in Minas Gerais, a state in the region with the lowest occurrence of the disease, although the indicator was classified as good, exceeding 90%, from 2008 to 2018, its trend was downward³¹31. Lages DS, Kerr BM, Bueno IC, Niitsuma ENA, Vidal SL, Reis GCS, et al. Avaliação do grau de incapacidade física por hanseníase em Minas Gerais. In: Farias HPS, org. Educação, saúde e sociedade: investigações, desafios e perspectivas futuras. Rio de Janeiro: Epitaya; 2022. p. 151-60.. Therefore, it is crucial to note that the trend and classification of this indicator presented in this study, with data for Brazil, conceal the significant variability that exists between regions of the country. In this context, monitoring the implementation of active tracking programs for leprosy cases becomes essential, providing opportunities for disease control and reducing the proportion of cases with a degree of physical disability at the time of diagnosis³²32. Souza MF, Vanderlei LCM, Frias PG. Assessment of the implementation of the Leprosy Control Program in Camaragibe, Pernambuco State, Brazil. Epidemiol Serv Saude 2017; 26(4): 817-34. https://doi.org/10.5123/S1679-49742017000400013
https://doi.org/10.5123/S1679-4974201700... ,³³33. Monteiro LD, Lopes LSO, Santos PR, Rodrigues ALM, Bastos WM, Barreto JA. Tendências da hanseníase após implementação de um projeto de intervenção em uma capital da Região Norte do Brasil, 2002-2016. Cad Saúde Pública 2018; 34(11): e00007818. https://doi.org/10.1590/0102-311X00007818
https://doi.org/10.1590/0102-311X0000781... .

The indicator proportion of cases cured in the year with the degree of physical disability assessed among new cases of leprosy is crucial for evaluating the effectiveness of disease control strategies. Early diagnosis and treatment can mitigate the risk of physical disability and consequently improve the quality of life for patients³⁴34. Silva JSR, Palmeira IP, Sá, AMM, Nogueira LMV, Ferreira AMR. Fatores sociodemográficos associados ao grau de incapacidade física na hanseníase. Rev Cuid 2018; 9(3): 2338-48.. A stationary trend was observed for this indicator, which, throughout all years of the investigated series, was classified as precarious. In Minas Gerais, a study conducted from 2008 to 2018 reported a regular classification for this indicator, but its decreasing trend led to a precarious level by the end of the series³¹31. Lages DS, Kerr BM, Bueno IC, Niitsuma ENA, Vidal SL, Reis GCS, et al. Avaliação do grau de incapacidade física por hanseníase em Minas Gerais. In: Farias HPS, org. Educação, saúde e sociedade: investigações, desafios e perspectivas futuras. Rio de Janeiro: Epitaya; 2022. p. 151-60.. These findings highlight persistent challenges in evaluating and monitoring post-cure patients to ensure comprehensive care, including assistance for rehabilitation if needed. This aligns with the recommendations of the Brazilian Unified Health System (Sistema Único de Saúde – SUS) for continued care and support¹¹11. Anchieta JJS, Costa LMM, Campos LC, Vieira MR, Mota OS, Morais Neto OL, et al. Trend analysis of leprosy indicators in a hyperendemic Brazilian state, 2001–2015. Rev Saúde Pública 2019; 53: 61. https://doi.org/10.11606/S1518-8787.2019053000752
https://doi.org/10.11606/S1518-8787.2019... ,²⁵25. Souza EA, Boigny RN, Ferreira AF, Alencar CH, Oliveira MLW, Ramos Júnior AN. Vulnerabilidade programática no controle da hanseníase: padrões na perspectiva de gênero no Estado da Bahia, Brasil. Cad Saúde Pública 2018; 34(1): e00196216. https://doi.org/10.1590/0102-311X00196216
https://doi.org/10.1590/0102-311X0019621... ,³³33. Monteiro LD, Lopes LSO, Santos PR, Rodrigues ALM, Bastos WM, Barreto JA. Tendências da hanseníase após implementação de um projeto de intervenção em uma capital da Região Norte do Brasil, 2002-2016. Cad Saúde Pública 2018; 34(11): e00007818. https://doi.org/10.1590/0102-311X00007818
https://doi.org/10.1590/0102-311X0000781... .

In the present study, the indicator proportion of recurrence cases among cases reported in the year exhibited an increasing trend. A time series study conducted in Bahia from 2001 to 2014 similarly noted an increasing trend for this indicator, pointing to a rise in the number of municipalities reporting recurrence cases from 2008 to 2014³⁵35. Souza EA, Heukelbach J, Oliveira MLWDR, Ferreira AF, Sena Neto SA, Raposo MT, Ramos Júnior AN. Low performance of operational indicators for leprosy control in the state of Bahia: spatiotemporal patterns, 2001–2014. Rev Bras Epidemiol 2020; 23: e200019. https://doi.org/10.1590/1980-549720200019
https://doi.org/10.1590/1980-54972020001... . Various predictive factors contribute to recurrence in patients diagnosed and cured, including treatment failure, reinfection linked to housing conditions and lifestyle habits, and the organization of health services. Additionally, professionals’ failure to differentiate recurrences from reactions post-discharge can also influence recurrence rates⁷7. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Diretrizes para vigilância, atenção e eliminação da Hanseníase como problema de saúde pública: manual técnico-operacional [Internet]. Brasília: Ministério da Saúde; 2016 [cited on Aug 14, 2023]. Available at: https://portal.saude.pe.gov.br/sites/portal.saude.pe.gov.br/files/diretrizes_para_._eliminacao_hanseniase_-_manual_-_3fev16_isbn_nucom_final_2.pdf
https://portal.saude.pe.gov.br/sites/por... ,³⁶36. Ferreira SMB, Ignotti E, Gamba MA. Factors associated to relapse of leprosy in Mato Grosso, Central-Western Brazil. Rev Saúde Pública 2011; 45(4): 756-64. https://doi.org/10.1590/s0034-89102011005000043
https://doi.org/10.1590/s0034-8910201100... . Given this perspective and considering the upward trend of the indicator, there is a pressing need to develop and implement strategies aimed at reducing determinants contributing to recurrence cases³⁷37. Feitosa ALM, Dourado Júnior FW, Florêncio CMGD. Tendência temporal da hanseníase em uma região de saúde do Ceará, 2001 a 2015. Medicina (Ribeirão Preto) 2020; 53(4): 438-46. https://doi.org/10.11606/issn.2176-7262.v53i4p438-446
https://doi.org/10.11606/issn.2176-7262.... ,³⁸38. Bona SH, Silva LOBV, Costa UA, Holanda AON, Campelo V. Recidivas de hanseníase em Centros de Referência de Teresina, Piauí, 2001-2008. Epidemiol Serv Saúde 2015; 24(4): 731-8. https://doi.org/10.5123/S1679-49742015000400015
https://doi.org/10.5123/S1679-4974201500... . It is crucial for services to distinguish relapse from situations involving reverse leprosy reaction, therapeutic insufficiency, and therapeutic failure. Cases unresponsive to proposed treatments for reactional states should be referred to reference units to confirm recurrence³⁹39. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Coordenação-Geral de Hanseníase e Doenças em Eliminação. Nota informativa no 51, de 15 de outubro de 2015. Nota Informativa sobre recidiva, insuficiência, falência e resistência medicamentosa na hanseníase [Internet]. Brasília: Ministério da Saúde; 2015 [cited on Feb 28, 2024]. Available at: https://www.saude.pr.gov.br/sites/default/arquivos_restritos/files/documento/2020-04/notainformativa51recidivaresisteinsuficienciamedicamentosanahanseniase.pdf
https://www.saude.pr.gov.br/sites/defaul... .

In summary, Brazil still faces significant challenges on the path to eradicating leprosy, as it remains among the five countries that have not achieved the control target proposed by the WHO, persisting with high levels of endemicity⁴⁰40. Luna IT, Beserra EP, Alves MDS, Pinheiro PNC. Adesão ao tratamento da Hanseníase: dificuldades inerentes aos portadores. Rev Bras Enferm 2010; 63(6): 983-90. https://doi.org/10.1590/S0034-71672010000600018
https://doi.org/10.1590/S0034-7167201000... . The continual high number of new cases poses a substantial obstacle to leprosy elimination, contributing to the emergence of new cases through household contacts⁴¹41. Blok DJ, De Vlas SJ, Richardus JH. Global elimination of leprosy by 2020: are we on track? Parasit Vectors 2015; 8: 548. https://doi.org/10.1186/s13071-015-1143-4
https://doi.org/10.1186/s13071-015-1143-... ,⁴²42. Pescarini JM, Strina A, Nery JS, Skalinski LM, Andrade KVF, Penna MLF, et al. Socioeconomic risk markers of leprosy in high-burden countries: a systematic review and meta-analysis. PLoS Negl Trop Dis 2018; 12(7): e0006622. https://doi.org/10.1371/journal.pntd.0006622
https://doi.org/10.1371/journal.pntd.000... . As demonstrated in this study, efforts to conduct contact exams, along with other indicators proposed by the leprosy control strategy, have fallen short. Moreover, the high incidence of the disease is closely intertwined with social determinants. Therefore, endemic countries like Brazil should integrate the eradication of poverty into their health policies. Actions within the health sector alone are deemed insufficient to address the diverse needs of the socially and economically marginalized populations⁷7. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Diretrizes para vigilância, atenção e eliminação da Hanseníase como problema de saúde pública: manual técnico-operacional [Internet]. Brasília: Ministério da Saúde; 2016 [cited on Aug 14, 2023]. Available at: https://portal.saude.pe.gov.br/sites/portal.saude.pe.gov.br/files/diretrizes_para_._eliminacao_hanseniase_-_manual_-_3fev16_isbn_nucom_final_2.pdf
https://portal.saude.pe.gov.br/sites/por... ,²¹21. Organização Mundial da Saúde. Rumo à zero hanseníase. Estratégia global para a hanseníase 2021-2030 [Internet]. Nova Deli: OMS, 2021 [cited on May 03, 2023]. Available at: https://www.who.int/pt/publications/i/item/9789290228509
https://www.who.int/pt/publications/i/it... ,⁴³43. Silvestre MPSA, Lima LNGC. Hanseníase: considerações sobre o desenvolvimento e contribuição (institucional) de instrumento diagnóstico para vigilância epidemiológica. Rev Pan-Amaz Saude 2016; 7: 93-8. https://doi.org/10.5123/s2176-62232016000500010
https://doi.org/10.5123/s2176-6223201600... ,⁴⁴44. Jesus ILR, Montagner MI, Montagner MA, Alves SMC, Delduque MC. Hanseníase e vulnerabilidade: uma revisão de escopo. Ciênc Saúde Coletiva 2023; 28(1): 143-54. https://doi.org/10.1590/1413-81232023281.09722022
https://doi.org/10.1590/1413-81232023281... .

Although the results underscore the imperative to enhance the quality of healthcare services to reduce leprosy, it is essential to acknowledge some limitations of this study. The epidemiological design employed restricts the observation and analysis of the quality of leprosy care provided within the specific context of Brazilian municipalities⁹9. Lima LV, Pavinati G, Silva IGP, Moura DRO, Gil NLM, Magnabosco GT. Temporal trend, distribution and spatial autocorrelation of leprosy in Brazil: ecological study, 2011 to 2021. Rev Bras Epidemiol 2022; 25: e220040. https://doi.org/10.1590/1980-549720220040
https://doi.org/10.1590/1980-54972022004... .

The limitations stemming from the utilization of secondary data from DATASUS must also be acknowledged, including gaps in data filling, the potential for underreporting, and inconsistencies in the flow of consolidated data within the system. However, leveraging this data enables access to a national registry encompassing a substantial final population, which is crucial for the epidemiological evaluation of neglected diseases. It can also facilitate assessment by managers and professionals, aiding decision-making and informing public health policy review and actions¹⁷17. Gonçalves ICM, Freitas RF, Aquino EC, Carneiro JA, Lessa AC. Mortality trend from falls in Brazilian older adults from 2000 to 2019. Rev Bras Epidemiol 2022; 25: e220031. https://doi.org/10.1590/1980-549720220031.2
https://doi.org/10.1590/1980-54972022003... ,⁴⁵45. Batista JFC, Oliveira MR, Pereira DLM, Matos MLSS, Souza IT, Menezes MO. Spatial distribution and temporal trends of AIDS in Brazil and regions between 2005 and 2020. Rev Bras Epidemiol 2023; 26: e230002. https://doi.org/10.1590/1980-549720230002
https://doi.org/10.1590/1980-54972023000... .

Furthermore, the temporal analysis of the effectiveness indicators of preventive measures and the attainment of their goals for eliminating leprosy in Brazil over a 20-year period enables the evaluation of the quality of healthcare services in implementing control actions. This process generates evidence that facilitates the adoption of strategies to address operational control challenges.

Furthermore, it is crucial to conduct further analyses with stratification according to regions so that policies can be tailored to the specific realities of each region of Brazil. Given the heterogeneous prevalence of the disease throughout the country and the vast territorial expanse, as well as the unequal distribution of resources, this adaptation is essential to ensure the effectiveness of health interventions.

Finally, given the current situation of leprosy in Brazil, it is imperative that the commitments outlined by the WHO for the elimination of the disease serve as guiding principles for the actions and policies implemented in the country. Addressing the challenges of overcoming delays in diagnosis, treatment, case monitoring, and active contact tracing requires financial investments to enable adequate training of professionals and improve the quality of healthcare services aimed at reducing leprosy in Brazil.

ACKNOWLEDGMENTS

To the Program for Scientific Initiation Support of the Amazonas State Research Support Foundation (Programa de Apoio à Iniciação Científica da Fundação de Amparo à Pesquisa do Estado do Amazonas – PAIC/FAPEAM), for granting the Scientific Initiation scholarship to student Gabriel da Silva Mártires, under the Institutional Program of Scientific Initiation Scholarships of Universidade Federal do Amazonas (Programa Institucional de Bolsas de Iniciação Científica da Universidade Federal do Amazonas – PIBIC/UFAM), Notice 026/2022.

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