Declining Leprosy-Related Hospitalization Rates and Increasing In-Hospital Case Fatality in Brazil: A Nationwide Ecological Time-Series Study, 2008-2023
Background:
Brazil reports more new leprosy cases than any country except India, yet whether the hospital burden of the disease has followed the decline in case detection is unknown.
Objective:
The objective of this study is to describe trends in leprosy-related hospital admissions in Brazil from 2008 to 2023, and in their in-hospital case fatality, length of stay, and cost. Methods: A nationwide ecological time-series study of all Brazilian Unified Health System (SUS) admissions with a primary diagnosis coded ICD-10 A30 (leprosy) or B92 (sequelae of leprosy), drawn from Hospital Information System microdata. Rates were directly standardized by age and sex to the 2022 Census population; costs were SUS reimbursements in constant 2023 Brazilian reais (R$). Average annual percentage changes (AAPCs) were estimated by Prais-Winsten regression.
Results:
Of 70,401 admissions, 1,026 (1.46%) ended in in-hospital death; reimbursements totaled R$ 87.3 million. The standardized hospitalization rate fell from 3.08 to 1.61 per 100,000 (AAPC -6.18%; 95% CI -8.07 to -4.25), significantly in four of five macro-regions, from -2.86% per year in the Northeast to -11.07% in the Central-West; in the South, the confidence interval (CI) included zero. Annual deaths did not decline (47 in 2008, 64 in 2023), and case fatality rose from 1.03% to 1.89% (AAPC +5.51%; 95% CI +4.22 to +6.81); the population-based standardized death rate showed no statistically significant trend (AAPC -1.74%; 95% CI - 3.74 to +0.30). Total cost fell by 4.45% per year (95% CI -7.33 to -1.49), and mean length of stay fell from 19.9 to 8.8 days. Cost per admission showed no significant trend over 2008-2023, but excluding 2008, when the national payment schedule changed, it fell by 1.41% per year (95% CI -2.28 to -0.53). Excluding sequelae (A30 only), the crude admission rate declined less and not significantly (AAPC -2.87%; 95% CI -6.23 to +0.62), whereas case fatality still rose (AAPC +4.09%; 95% CI +1.95 to +6.28). Most admissions were in men (46,068; 65.4%); 2,684 (3.8%) occurred before age 15.
Conclusions:
Leprosy-related hospitalization rates declined, while in-hospital deaths did not, and case fatality among admitted patients increased. More severe disease among those admitted, changes in access or admission practice, and coding may each contribute to this divergence; these data cannot distinguish them.