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.