Leprosy Mailing List, April 23^rd, 2009

Ref.:    Brazil, “Nota Técnica” n. 010/2007 (see attachments in English and Portuguese)

From:  W. de Oliveira M. L., Rio de Janeiro, Brazil

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<< “Nota Técnica” n. 010/2007 English >>

<< “Nota Técnica” n. 010/2007 Portuguese >>

 

 

 

Dear Salvatore,

Concerning the latest communications about Brazil on the leprosy mailing list, I would like to share some personal comments.  Not because I have been  involved in making National Policy since the introduction of MDT, but especially as a health professional dealing with Hansen´s Disease problems in Brazil , from  patients' assistance to the management programme at different levels, since 1975.

What is the use of the fuss made over leprosy "elimination" versus control inBrazil ?

 

The Brazilian National Hansen’s Disease Control Programme (Health Surveillance Secretariat of the Federal Ministry of Health) issued technical note nº 10 in 2007, which I have attached for rereading/highlighting the indicators of annual detection of new cases and cases among children as the most appropriate for monitoring the leprosy situation, particularly when trends are analysed over time.  Prevalence, the indicator contemplated in the elimination goal, would be maintained for the purposes of comparison with other countries, but not as a monitoring indicator, given that the public health problem does not end upon reaching a level of less than one case per 10,000 population.   It is important to emphasise that the indicator that most directly affects this outcome is the cure rate, which has been prioritised by the National Hansen’s Disease Control Programme (PNCH) and formally agreed upon by the federal, state and municipal authorities of the Unified Health System (SUS).  In addition, the reduction of cases in children under 15 has been included among the high-priority goals of the Ministry of Health (MoH) as part of the national Programme for Growth Acceleration (PAC).

 

The technical guideline in question was issued on the basis of analyses of national data conducted by technicians with no political interest in the outcomes, which unequivocally demonstrate the effect that changes in the calculation of the leprosy detection and prevalence indicators had in Brazil from 2004-06, namely an artificial reduction in the number of new cases.  This report was submitted to two technical bodies, one composed of renowned Brazilian epidemiologists and representatives of the Brazilian Association of Post-Graduate Studies in Community Health, as well as to the Evaluation Committee of the National System of Health Surveillance of the MoH, whose president was the former ex-director of PAHO, Dr. Carlyle Guerra.

 

The technical note was also presented to the Technical Advisory Committee of the PNCH in July 2007, and it was approved by this body, which included the consent of the MORHAN representative. In August 2007, the document was made available on the MoH website as well as during numerous national and international scientific events.  

 

In all of these cases, there was no opposition to the document on technical grounds put forward by anyone working in the levels of management or execution of the action plans for Hansen’s disease control either in Brazil or abroad.  Neither was any negative manifestation made by the non-governmental organisations (NGOs) that support the state control programmes in Brazil , as was stated in the discussions on the mailing list.

 

So, why the ruckus now, brought upon by an article in a single Brazilian newspaper?  In light of this, I would like to personally answer some of the affirmations made in that story:

1-To the examples given by MORHAN of elimination of diseases such as rubella and poliomyelitis: It is not necessary to discuss this fact when dealing with immunisable diseases. Why is it, however, that no one has the elimination of tuberculosis as a primary goal when it is a disease with the same intervention/control model as leprosy?

2-To the arguments of Dr. Jarbas Barbosa in reference to the fact that Brazil would eliminate leprosy in three years: according to the evidence presented in the technical note (attached), this could actually have been possible, but only using artificial mechanisms.

3-To Dr. Clovis Lombardi, Brazilian public health physician and retiree of PAHO: I have no comment to make. I have also worked in leprosy for 30 years, with local, regional and national experience. I am not retired, but when I am, I hope to have a good answer to questions like: what was my tangible contribution to the solution of the leprosy PROBLEM in my country?

 

Lastly, Brazil is a relatively young and extensive country, where leprosy was introduced 500 years ago; where it took three centuries to formulate the first policy of intervention; and where a therapeutic approach to case resolution only appeared 50 years ago, the contingent of infected individuals has still not been exhausted is still being diagnosed. This is due to the characteristics inherent to this disease, such as a long incubation period and the insidious evolution of its multibacillary forms.

 

In addition to the historical factors and technical/scientific evidence that explain why the number of new cases of leprosy alone does not allow for the achievement of the elimination goal in 2010, there is also the social and political context that interferes with the effectiveness of control measures.  The elimination goal helped to clear the registries, but it has run its course.  The active registry of leprosy patients is now relatively up to date, which is why the prevalence is now nearly exclusively made up of incident cases. Therefore, the stabilisation of the leprosy endemic has already occurred in the most developed regions for over a decade, but is only now starting to appear in the three more impoverished regions, according to recent epidemiological trend studies (www.saude.gov.br/svs)

 

To stir up an unnecessary row and blame federal officials now, simply to create more political pressure, is both a sterile and tiresome discussion. It is even harder to understand when it originates from the local social movement, which would be so much more effective if it were mobilising social interventions in conjunction with local health officials in the most endemic areas in order to intensify control activities and eliminate (yes, eliminate) the focal points of transmission in existence in Brazil.

 

I recommend the reading of Dr. Wagner Nogueira’s recent contribution to the mailing list (LML April 21^st, 2009).  He is a physician that has truly been active in the control of Hansen’s disease in São Paulo state with an important national role over the years and an involvement in the early leadership to found MORHAN.  His missive is particularly salient when he refers to the ambition of some partners to occupy positions of power and the questionable ethical aspect of taking complex technical discussions to the media for wider dissemination.

 

Maria Leide W. de Oliveira

 

Professor/Medical School of the Federal University of Rio de Janeiro (UFRJ)

mleide (at) hucff.ufrj.br