CONTROL AND PREVENTION OF LEPROSY IN DIFFICULT TO REACH AREAS OF AMAZONAS, THROUGH TELEHEALTH TECHNOLOGY

Luiz Claúdio Dias, Valderiza Pedrosa, Leila Brasil, Maria Leide Wand-Del-Rey, York Lunau, Carolina Talhari

Alfredo da Matta Foundation, , Amazonas, Brazil Federal University of Rio de Janeiro, Rio de Janeiro, Brazil Novartis Foundation for Sustainable Development, Basel, Switzerland Acknowledgments

Adriana Raposo Maria de Fátima Maroja Alexandra Costa Nádia Pimentel Andrezza Nunes Nádia Picanço Carlos Alberto Chirano Roger Assis Emília Pereira Rossilene Cruz Hanna Pereira Valdenora Rodrigues Ione Freire Valdelina Pereira Jamile Izan Júnior Leandro Fortes Leila Brasil Maria Anete Queiroz Maria Angêla Torrecila Maria da Graça Cunha Leprosy prevalence rates, data reported to WHO - 2012

http://gamapserver.who.int/mapLibrary/app/searchResults.aspx http://http://www.ezilon.com/maps/south-america/brazil-maps.html New leprosy case detection in Amazonas, Manaus and other , 1989-2012

CountrysideCountryside

SINANET/GEP/Subinfort/Fundação Alfredo da Matta, Manaus Detection of new leprosy cases in Humaitá, Amazonas, Brazil

Local general practitioners

SINANET/GEP/Subinfort/Fundação Alfredo da Matta, Manaus Detection of new leprosy cases in Humaitá, Amazonas, Brazil

Local general practitioners Alfredo da Matta’s staff

SINANET/GEP/Subinfort/Fundação Alfredo da Matta, Manaus Detection of new leprosy cases in Novo Aripuanã, Amazonas, Brazil

SINANET/GEP/Subinfort/Fundação Alfredo da Matta, Manaus Average cost of theoretical course on leprosy for health workers from other municipalities in Manaus

2013

People trained 37 2

Course’s duration (days) 5

Accommodation ($) 39.00 20.00

Transportation ($) 161.50 960.00

Personal expenses ($) 42.50 52.00

TOTAL ($) per participant 569.00 2.640,00 Average cost of monitoring leprosy in difficult to reach municipalities in Amazonas State

Lábrea

2012 2013 Visit frequency Every two years Every 6 months Staff 5-7 2 Visit’s duration 7 days 5 days Accommodation ($) 20.00 20.00 Transportation ($) 960.00 960.00 Personal expenses ($) 32.00 52.00 Patients attended 300-400 people 80 people New leprosy cases 7 (during the year) 7 TOTAL ($) 7,220.00 – 10,108.00 2.640,00 CONTROL AND PREVENTION OF LEPROSY IN DIFFICULT TO REACH AREAS OF AMAZONAS, BRAZIL THROUGH TELEHEALTH TECHNOLOGY

CONTROL AND PREVENTION OF LEPROSY IN DIFFICULT TO REACH AREAS OF AMAZONAS, BRAZIL THROUGH TELEHEALTH TECHNOLOGY

. General objective: to control and prevent leprosy in difficult

to reach areas of Amazonas through telehealth technology

CONTROL AND PREVENTION OF LEPROSY IN DIFFICULT TO REACH AREAS OF AMAZONAS, BRAZIL THROUGH TELEHEALTH TECHNOLOGY

. Specific objective:  Train health workers from and Labrea in telehealth technology

 Theoretical training in leprosy for local health workers through telehealth technology  Establishment of a virtual clinic

 Monitoring activities

 Leprosy patients NGO units foundation outside Manaus http://www.v-brazil.com/tourism/amazonas/map-amazonas.html MANAUS PARINTINS

LÁBREA PAHO’s referral center for the diagnosis and treatment of leprosy

Referral center for the diagnosis and treatment of leprosy in Brazil Brazilian program for leprosy control and prevention – Amazonas State Training in telehealth tecnology at Alfredo da Matta Foundation

Telehealth center in Labrea before project initiation Telehealth center in Labrea after project initiation

20 Training in telehealth tecnology at Labrea’s telehealth center Telehealth center Paritins after project initiation Training in telehealth tecnology at Parintins’s telehealth center Total number of health workers trained in telehealth technology in Parintins and Labrea since April 2013

Health workers Lábrea Parintins

Physician 2 8 Nurse 8 19 Physiotherapist 5 Social worker 4 Dentist 1 8 Health technician 3 3 Nutritionist 1 Health care 1 TOTAL 16 47 Theoretical course on leprosy for Labrea health workers Theoretical course on leprosy for Parintins health workers Theoretical training in leprosy

LEPROSY Clinical aspects Classification Diagnosis and treatment Leprosy reaction management Differential diagnosis Physical disabilities prevention and self-care Active case finding Social aspects of the disease Theoretical training in leprosy

LEPROSY Skin examination Clinical aspects of leprosy Treatment administration Physical disabilities prevention and self-care Active case finding Total number of health workers trained in leprosy through telehealth in Parintins and Labrea since April 2013 Dermatological consultation through telehealth to difficult to reach municipialities – a much needed help

Adriana Raposo, dermatologist Carla Ribas, dermatologist Carlos Chirano, dermatologist Carolina Talhari, dermatologist Luiz Cláudio, dermatologist Mônica Santos, dermatologist Nádya Picanço, dermatologist Patricia Morais, dermatologist Carolina Cunha, physician Emilia Pereira, nurse Anete Queiroz, nurse

30 Synchronous telehealth

Asynchronous Telehealth - Virtual clinic Parintins and Labrea

Monitoring&Evaluation the project in Lábrea and Parintins - August 2013

• Visit to 9 local health units

• Interview with the health workers trained in leprosy through telehealth technology

• Visit to rural communities with local health workers

• Local MORHAN (leprosy patients NGO) unit was implemented

• Local Self-care group was implemented

Total number of patients examined by Alfredo da Matta’s staff in Labrea during monitoring - August 2013

Lábrea

City area Lábrea river Dermatological examination 148 152 New leprosy cases 5 2

3 children

Average cost of theoretical course on leprosy for health workers from other municipalities in Manaus

2013 2013 Telehealth

People trained 37

Course’s duration (days) 5

Accommodation ($) 39.00

Transportation ($) 161.50

Personal expenses ($) 42.50

136

TOTAL ($) per participant 569.00 Comparison between the average cost of theoretical course on leprosy for health workers from other municipalities in Manaus and through telehealth technology 2013 2013 Telehealth

People trained 37 488

Course’s duration (days) 5

Accommodation ($) 39.00 -

Transportation ($) 161.50 -

Personal expenses ($) 42.50 -

Telehealth project investment 136,800

TOTAL ($) per participant 569.00 280.33 Average cost of leprosy monitoring in difficult to reach municipalities in Amazonas State

Lábrea

2012 2013 Visit frequency Every two years Every 6 months Staff 5-7 2 Visit’s duration 7 days 5 days Accommodation ($) 20.00 20.00 Transportation ($) 960.00 960.00 Personal expenses ($) 32.00 52.00 Patients attended 300-400 people 80 people New leprosy cases 7 (during the year) 7 TOTAL ($) 7,220.00 – 10,108.00 2.640,00 Comparison between the average cost of leprosy monitoring in difficult to reach municipalities in Amazonas State before and after telehealth technology implementation Lábrea

2012 2013 (wtih telehelath) Visit frequency Every two years Every 6 months Staff 5-7 2 Visit’s duration 7 days 5 days Accommodation ($) 20.00 20.00 Transportation ($) 960.00 960.00 Personal expenses ($) 32.00 32.00 Patients attended 300-400 people 80 people New leprosy cases 7 (during the year) 7 (during one week) TOTAL ($) 7,220.00 – 10,108.00 2.640,00 Low costs of leprosy monitoring&evaluation in difficult to reach municipalities of Amazonas with telehealth technology

•  Visit frequency – less people at low costs

•  staff and visit’s duration:  theoretical courses on leprosy are performed through telehealth  Pre-screening of patients made by local health workers  Monitoring of epidemiological aspects are made through telehealth  Virtual clinic

Positive aspects of the project in Parintins and Lábrea

• Local health workers became more aware of leprosy after training

• Active case finding were conducted by local health workers after training

• All primary health units are performing skin examination on a routine basis

• Identification of new cases of leprosy Positive aspects of the project in Parintins and Lábrea

• All equipment provided for telehealth are in its own room and in good condition

• Self-care groups were created both in Parintins and Labrea

Negative aspects of the project in Parintins and Labrea

• Poor internet connection quality in some municipalities

• Necessity of printed material for the theoretical courses on leprosy

• Health personnel turn-over  necessity of a permanent training in leprosy

What else is possible through telehealth technology?

Secondary benefits… http://www.v-brazil.com/tourism/amazonas/map-amazonas.html

Number of health workers from indigenous area trained in leprosy through telehealth - 2013

INDIGENOUS PROFESSIONAL NUMBER OF HEALTH MUNICIPALITIES CATEGORY PARTICIPANTS DISTRICT Anamã, ,Itacoatiara, Nova Olinda, Nurse 20 MANAUS , , Manaus, Manicoré, , Novo Airão Health technician 6 Physician 1 ALTO RIO Nurse 9 NEGRO São Gabriel da Cachoeira DSEI - ARN Pharmacist 1 Health technician 8 Nurse 23 ALTO RIO , Benjamin Constant, São Paulo de Social worker 1 SOLIMÕES Olivença, Amaturá DSEI - ARS Health technician 13 Laboratorial technician 1 Nurse 02 PARINTINS Parintins Health technician TOTAL:03 88 Videoconferences with health workers from indigenous area in São Gabriel da Cachoeira through telehealth - 2013

Professional Municipiality Participants categories Physician 4 Nurse 12 São Gabriel da Pharmacist 1 Cachoeira Psicologist 1 Health technician 22 Laboratory technician 2 TOTAL: 42 Specials groups for discussion:

 Dermatology  Leprosy

Acknowledgments